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R  D33  B76  1 909       700  surgical  suggest 


RECAP 


URSIGAL  SUGGESTIONS 

Vv'Ai.TER  ML  BRICKNER,  M,  D. 
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SURGICAL  SUGGESTIONS 


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SURGICAL  SUGGESTIONS 

PRACTICAL  BREVITIES 
IN    DIAGNOSIS   AND   TREATMENT 


WALTER  M.  BRICKNER,  B.S.,  M.D. 

Assistant  Adjunct  Surgeon^  Mount  Sinai  Hospital ; 
Editor-in-Chief.  American  Journal  of  Surgery^  New  York. 

ELI  MOSCHCOWITZ,  A.B.,  M.D. 

Assistant  Physician,  Mount  Sinai  Hospital  Dispensary  ; 
Associate  Editor,  American  Journal  of  Surgery,  New  York, 


HAROLD  M.  HAYS,  M.A.,  M.D. 

Associate  Editor,  American  Journal  of  Surgery,  New  York. 

THIRD   SERIES 


new  york,  u.  s.  a. 

Surgery  Publishing  Company 

92  william  strfet 

1909 


Copyright,  1909 

BY 

Surgery  Publishing  Company 


7?7>33 


PREFACE 

The  flattering  reception  accorded  to  the  first  issue 
of  "  Surgical  Suggestions,"  published  in  1 906,  and  the 
second  series,  "  Five  Hundred  Surgical  Suggestions," 
1907,  has  encouraged  us  to  meet  the  demand  for  this 
little  book  by  the  preparation  of  a  larger  series. 

To  the  "Suggestions"  included  in  the  earlier  editions 
about  two  hundred  have  been  added,  many  of  these  by 
Dr.  Hays. 

Dr.  Percy  Fridenberg  has  contributed  to  this  issue 
several  of  the  Suggestions  relating  to  atf ections  of  the  eye 
and  ear. 

These  brevities  are  presented  merely  as  random 
practical  observations. 

W.  M.  B. 


December,  1908. 


HEAD. 


700 
SURGICAL  SUGGESTIONS. 


Transverse  scalp  wounds  require  compara-     Scalp, 
tively  many  sutures,  longitudinal  wounds  but 
few. 

Placing  the  skin  sutures  in  the  scalp 
obliquely  will  often  control  hemorrhage  from 
a  wound  as  well  as  will  ligating  separate 
vessels. 

If  a  scalp  wound  extends  through  the  peri- 
osteum it  is  safest  to  sew  the  periosteal  wound 
at  once  and  leave  the  scalp  unsutured  for 
twenty-four  hours.  Fracture  should  be  ex- 
cluded, if  possible,  before  closing  the  peri- 
osteum. 

Depilatories  are  useful  in  the  preparation 
of  the  scalp  for  the  treatment  of  abscesses 
or  infected  wounds,  when  the  nature  of  the 
infection  or  the  matted  condition  of  the  hair 
makes  shaving  difficult. 

A  small,  hard,  irregularly  nodular  scalp 
tumor  is  very  likely  an  endothelioma.     A  lit- 


MEAD. 


tie  section  should  be  removed  under  local 
anesthesia  for  miser oscopical  examination.  If 
the  diagnosis  is  corroborated,  radical  removal 
is  necessary. 

Lipomata  of  the  scalp  often  undergo  cystic 
degeneration.  A  tumor  v^^hich  grossly  may 
look  like  a  lipoma,  may  show  under  the 
microscope  evidences  of  sarcoma.  Fortu- 
nately these  sarcomata  of  the  scalp  do  not 
often  form  metastases. 

Lipoma  of  the  scalp  may  also  simulate  a 
wen.  Both  grow  gradually,  are  semi-fluctu- 
ating and  are  movable  on  the  deeper  parts. 
Aspiration  for  diagnostic  purposes  is  not  a 
wise  procedure;  for  if  the  tumor  be  a  cyst, 
the  contents  may  readily  flow  out  through  a 
puncture  hole,  making  it  difficult  to  remove 
the  cyst  wall  at  operation. 

A  small  meningocele  may  resemble  a  seba- 
ceous cyst.  The  previous  history  is  important 
in  the  diagnosis.  A  meningocele  of  this  char- 
acter is  present  "as  long  as  the  patient  can 
remember"  and  remains  about  the  same  size; 
a  cyst  begins  as  a  small  nodule  later  on  in 
life  and  increases  in  size. 


MEAD. 


A  severe  neuralgia  at  the  back  of  the  head 
and  neck  in  many  instances  can  be  reheved 
when  all  other  means  have  failed,  by  sever- 
ance of  the  occipital  nerves.  A  palliative 
remedy  is  the  injection  of  cocain  over  the  seat 
of  the  nerve. 

Strong  antiseptic  solutions  should  be  avoid- 
ed in  dressing  scalp  v/ounds.  For  "wet  dress- 
ings" Thiersch's  (boro-salicylic)  or  Burow's 
(aluminum  acetate)  solution  is  sufficiently 
antiseptic. 

An  easy  means  of  holding  a  small  scalp 
dressing  in  place  consists  in  tying  over  it 
strands  of  the  patient's  hair. 

If  the  patient  is  a  brunette  and  a  small 
scalp  dressing  is  applied  without  a  bandage 
as  above  described,  the  white  gauze  should 
be  covered  by  a  piece  of  black  or  brown 
cloth,  unless  the  patient  has  enough  hair  to 
conceal  a  small  dressing.  Black  bandages 
may  be  used  to  advantage  in  scalp  dressings 
on  dark-haired  individuals. 

For  the  retention  of  an  application  or  dress- 
ing on  the  scalp  a  gauze  cap  may  be  more 
quickly  applied  than  a  bandage  and,  for  chil- 


HEAD. 


Cranium. 


dren  especially,  it  will  be  more  comfortable 
and  less  apt  to  be  disarranged.  A  single 
thickness  of  gauze  (cheese  cloth)  about  a 
yard  long  and  28  inches  wide  (for  an  adult 
head)  is  folded  on  its  length,  in  the  manner 
shown  in  figure  1.      The  gauze  is  then  laid 


Fig.  1 


on  the  head,  with  the  long  fold  next  to  the 
scalp  and  the  folded  end  a  little  below  the 
occiput,  the  free  end  of  the  long  fold  thus 
hanging  over  the  face.  The  free  edge  of  the 
short  fold  is  brought  to  a  convenient  posi- 
tion, and  its  ends  are  tied  snugly  under  the 
chin  (figure  2).  Then  the  long  end  is  lifted 
back  over  the  short  end  and  tied  snugly  be- 
neath the  occiput  (figure  3).  The  cap  thus 
adjusted  consists  of  three  thicknesses  of  gauze. 

In  determining  whether  or  not  to  operate 
after  injuries  to  the  head,  a  surgical  judg- 
ment of  the  case  is  usually  better  than  one 
based  strictly  on  the  application  of  neuro- 
logical rules. 

lO 


HEAD. 


There  is  no  class  of  cases  in  which  a  prog- 
nosis is  so  often  at  variance  with  the  extent 
of  the  injury  as  in  cranial  injuries.  The 
prognosis  in  such  cases  should,  therefore,  al- 
ways be  guarded. 

In  cases  of  head  traumata,  bleeding  from 
the  mouth  or  nose  does  not  necessarily  mean 
that  the  case  is  one  of  fracture  at  the  base. 
The  hemorrhage  may  be  entirely  due  to  a 
localized  injury. 

In  fractures  of  the  base  of  the  skull  with 
bleeding  from  the  ear  it  is  necessary  to  keep 
the  auditory  canal  absolutely  clean  in  order 
to  prevent  infection  of  the  meninges. 

In  cases  of  suspected  fracture  of  the  skull, 
percussion-auscultation  will  be  found  a  valu- 
able diagnostic  procedure:  The  forehead  is 
repeatedly  tapped  sharply  in  the  median  line 
with  the  middle  finger,  the  stethoscope  being 
moved  from  one  point  to  another  from  before 
backward.  If  a  fracture  be  present,  a 
cracked-pot  sound  is  elicited  just  beyond  it. 
The  corresponding  part  of  the  head  on  the 
other  side  should  be  auscultated  to  eliminate 
possible  error. 


II 


HE4D. 


**Egg  shell  crackle"  elicited  in  palpating 
a  tumor  of  the  cranial  bones  is  diagnostic  of 
sarcoma  originating  in  the  diploe. 


&rain. 


Tumors  of  the  brain  frequently  simulate, 
in  their  earlier  stages,  diseases  of  the  stomach. 


Increasing  deafness  and  blindness  should 
suggest  an  intracranial  tumor,  especially  if 
facial  palsy  be  present. 

When  an  operation  is  performed  for  re- 
moval of  a  tumor  at  the  base  of  the  brain, 
one  should  be  careful  to  retract  upward 
(pressing  on  the  hemispheres)  instead  of 
pressing  downward  (on  the  medulla),  which 
may  paralyze  the  vital  centers. 

In  exploring  for  tumors  of  the  brain,  the 
best  guide  for  determining  an  isolated  hard- 
ness is  the  finger;  the  use  of  a  needle  is  very 
deceptive. 

In  cases  of  brain  tumor  lumbar  puncture 
may  cause  sudden  death. 

Car.         A  furuncle  deeply  situated  in  the  external 
auditory  canal  gives  signs  that  may  be  mis- 


12 


MEAD. 


taken  for  mastoiditis.  Great  pain  when  the 
concha  is  moved  about,  will  serve  to  differ- 
entiate it  from  the  latter. 


Don't  incise  every  furuncle  of  the  audi- 
tory canal.  Tampon  with  a  wick  of  cot- 
ton or  gauze  saturated  with  liquor  Burowii 
(acetate  of  aluminum),  resorcin-alcohol,  or 
balsam  of  Peru,  and  wait  until  pain  has  dis- 
appeared. Hot  applications  may  be  needed. 
A  furuncle  pointing  and  threatening  to  burst 
may  be  opened  with  a  superficial  cut.  Avoid 
wiping  the  pus  along  the  canal,  as  the  result 
is  almost  inevitably  a  fresh  crop  of  furuncles. 

Pain  in  the  ear,  increased  on  traction  of 
the  auricle,  with  slight  diminution,  if  any,  of 
hearing,  suggests  a  furuncle  in  the  meatus. 
Introduce  the  speculum  with  great  care.  The 
probe  will  often  reveal  a  point  of  marked 
tenderness. 

One  should  not  try  to  force  his  way  into 
an  auditory  canal  without  first  making  sure 
that  the  patient  has  no  disease  of  the  external 
ear.  The  examination  under  such  circum- 
stances will  only  aggravate  the  condition. 


13 


MEAD. 


Severe  and  repeated  headaches  may  be 
due  to  the  unsuspected  presence  of  otitis 
media,  with  or  without  mastoiditis. 

Sudden  one-sided  diminution  of  hearing 
after  bathing  may  indicate  nothing  more  seri- 
ous than  water  in  the  ear,  or  a  plug  of  wax 
which  has  swelled  up  and  obstructed  the 
canal.  If  no  means  of  syringing  is  at  hand, 
the  instillation  of  ether  and  alcohol,  equal 
parts,  will  dry  up  the  plug  and  often  cause 
it  to  disintegrate,  with  a  corresponding  im- 
provement in  hearing.  Swollen  seeds,  peas 
or  beans  in  the  external  canal  can  be  treated 
similarly. 

Don't  pour  hot  oil  into  the  ear  to  relieve 
pain.  Heat  can  be  applied  much  better  in 
a  hot  mixture  of  glycerin,  alcohol  and  water, 
which  will  not  turn  rancid  or  clog  up  the 
ear,  and  can  be  removed  by  syringing  with 
water.  A  towel  or  large  pad  of  gauze  wrung 
out  in  boiling  water  and  closely  applied  over 
the  ear,  covered  with  oiled  silk  or  rubber 
tissue,  is  better  than  a  hot  water  bag. 

A  neuralgic  pain  in  the  region  of  the  ear, 
should  suggest  a  careful  examination  of  the 
teeth  for  caries  or  alveolar  inflammation. 


14 


MEAD. 


Three  or  four  drops  of  peroxid  of  hydro- 
gen in  the  ear  followed  live  minutes  later  by 
thorough  syringing  with  a  solution  of  boracic 
acid  or  bicarbonate  of  soda,  will  readily  re- 
move impacted  cerumen. 

In  cases  of  unaccountable  fever,  especially 
in  children,  never  fail  to  examine  the  ear. 

Tinnitus  aurium,  present  only  in  the  re- 
cumbent posture,  is  suggestive  of  aneurism  of 
one  of  the  posterior  cerebral  vessels. 

The  history  of  a  discharge  from  an  car 
appearing  a  few  days  to  a  few  weeks  after 
the  beginning  of  a  slowly  developing  deafness 
in  that  ear,  unaccompanied  at  any  time  by 
pain,  is  suspicious  of  tuberculous  otitis  media. 

Intermittent  mucoid  or  mucopurulent  dis- 
charge from  the  ear  without  pain  or  fever 
suggests  nasopharyngeal  disease;  in  children, 
adenoids. 

A  bean-shaped  pulsating  swelling  just  be- 
low the  mastoid  apex,  in  cases  of  mastoiditis, 
may  be  only  a  lymphatic  gland,  but  it  may 
also  be  a  thrombosed  jugular  vein.     Its  nature 


15 


HEAD. 


should   therefore   be   determined   before   the 
operation  is  concluded. 

"Paracentesis"  is  a  misnomer.  The  drum 
should  be  slit  from  below  upwards  and  near 
the  posterior  margin,  throughout  its  entire  ex- 
tent. In  withdrawing  the  knife  it  may  be  al- 
lowed to  cut  deeply  into  the  upper  canal  wall 
near  the  drum  (internal  Wilde's  incision). 

An  old,  narrow  Graefe  cataract  knife  is 
an  ideal  instrument  for  opening  the  drum 
membrane  in  otitis.  Ethyl  chlorid  marcosis 
is  the  best  for  this  brief  operation. 

Irrigation  of  the  ear  with  a  warm  boric 
acid  solution  (108°  F.),  is  an  excellent  pro- 
cedure if  there  is  a  discharge  of  pus.  But 
irrigation  of  the  ear  just  after  a  paracentesis 
of  the  drum  or  when  there  is  only  a  serous 
discharge,  merely  predisposes  the  mucous 
membrane  and  the  mastoid  to  greater  infec- 
tion. 

Pain  and  tenderness  behind  the  ear  is  not 
always  indicative  of  mastoid  disease.  One 
should  not  forget  to  look  for  pediculi  in  the 
scalp,  for  they  often  lead  to  an  infection  of 
the  deep  cellular  tissues  in  this  region. 


i6 


HEAD. 


The  cessation  of  a  purulent  discharge  from 
the  ear  should  not  be  taken  as  a  sign  of  cure. 
The  pus  may  have  found  its  way  into  the 
mastoid  cells. 

Persistent  suppuration  in  a  mastoid  wound 
in  most  cases  means  dead  bone  at  the  bottom 
of  the  cavity. 

During  mastoid  operations  always  sever 
with  scissors  any  fragment  of  tissue  attached 
to  a  bit  of  bone  loosened  with  the  chisel  or 
rongeur,  before  removing  it.  The  tearing  out 
of  a  fiber  of  the  sterno-mastoid  muscle,  for 
example,  will  open  a  channel  of  infection  in 
the  neck. 

If  the  zygomatic  cells  are  thoroughly  laid 
open,  one  frequent  cause  of  persistent  sup- 
puration requiring  secondary  mastoid  opera- 
tion, may  be  avoided. 

A  persistent  elevation  of  temperature  after 
a  radical  operation  for  mastoiditis  should 
lead  one  to  suspect  the  possibility  of  a  com- 
plicating brain  abscess.  If  the  fever  shows 
wide  fluctuations  of  temperature  a  sinus 
thrombosis  is  more  probably  the  cause. 


17 


MEAD. 


Nitrate  of  silver  may  be  attached  in  full 
strength  to  the  end  of  a  probe,  as  for  appli- 
cation in  the  middle  ear,  by  heating  the  tip 
of  the  instrument  and  pressing  it  into  the 
stick  of  caustic;  a  little  of  the  latter  will 
melt  and  form  a  bead  on  the  probe  when  it 
cools. 

Eye.  Cystic  swellings  at  the  external  angle  of 

the  eye  are  usually  dermoids.  In  some  cases 
they  communicate  by  a  small  opening  with 
an  intracranial  sac. 

An  opaque  growth  on  the  eyeball  in  a 
child  is  likely  to  be  a  dermoid  growth — that 
is,  a  growth  of  skin  epithelium  on  the  con- 
junctiva. 

A  stye  is  often  most  easily  treated  by  the 
removal  of  the  hair  in  the  infected  follicle 
and  the  subsequent  application  of  iced  boracic 
acid  compresses. 

Clipping  the  lashes  close  before  ophthalmic 
operations  renders  the  first  dressing  easy,  as 
the  lids  are  not  glued  together,  there  is  no  re- 
tention of  secretion,  and,  accordingly  there  is 
less  danger  of  secondary  infection. 

i8 


HEAD. 


A  hyperdermatic  injection  of  morphin,  gr. 
1/6,  about  a  half  hour  before  a  major  eye 
operation,  such  as  cataract  or  iridectomy,  will 
keep  the  patient  quiet  and  make  the  extrac- 
tion calm,  and  free  from  pain.  There  is  no 
danger  of  sudden  motion  of  the  head,  and  the 
tcchnic  is  more  exact  and  rapid. 

A  one-sided  conjunctivitis  or  irritative  con- 
dition, with  tearing,  photophobia,  and  lid- 
spasm  should  always  suggest  the  presence  of 
a  foreign  body  on  the  cornea  or  behind  the 
lid.  In  the  latter  case  puffiness  of  the  upper 
lid  develops  very  rapidly  and  is  a  diagnostic 
aid.  A  dark  body  is  best  seen  against  the 
iris;  a  light  one,  against  the  pupil.  The 
patient's  eye  should  be  turned  accordingly. 

In  looking  for  a  foreign  body  on  the  sur- 
face of  the  eye,  examine  the  tear-points  with 
care.  An  incarcerated  lash  or  cut  end  of 
hair  may  be  the  cause  of  the  trouble. 

By  pressing  lightly  with  the  flat  end  of  a 
wooden  toothpick  in  the  region  of  a  foreign 
body  on  the  cornea,  it  will  often  come  away. 
The  conjunctiva  should  first  be  anesthetized 
with  a  solution  of  cocain. 


19 


HEAD. 


After  the  extraction  of  a  foreign  body 
from  the  cornea,  a  drop  of  castor  oil  be- 
tween the  lids  will  ameliorate  the  pain. 

The  sensation  of  a  foreign  body  in  the 
eye  may  be  provoked  by  the  presence  of  a 
small  tarsal  tumor. 

"Black  eye,"  developing  in  an  infant, 
without  any  history  of  injury,  should  always 
arouse  suspicion  of  scurvy  (Barlow's  dis- 
ease). It  is  generally  distinguished  by  lack 
of  swelling,  absence  of  bruise  or  redness  of 
lids,  and  rapid  gravitation  of  the  blue  dis- 
coloration to  the  lower  lid  and  cheek.  The 
orbital  hemorrhage  may  take  place  on  the 
other  side,  after  a  short  interval. 

Recurrent  attacks  of  inflamed  lids,  con- 
junctivitis, or  corneal  ulcer  in  one  eye,  suggest 
an  infected  lacrimal  sac.  Pressure  over  the 
inner  canthus  will  generally  cause  muco-pus 
to  present  in  the  puncta. 

Small  incised  wounds  over  the  eyelid  are 
very  prone  to  infection.  Instead  of  sewing 
up  the  wound  immediately,  put  on  a  wet 
dressing  and  wait  twenty-four  hours. 


20 


HEAD. 


Constant  lacrimation  with  no  other  signs  or 
symptoms  may  be  due  to  a  chronic  dacryo- 
cystitis. Removal  of  the  lacrimal  sac  will 
often  efFect  a  cure. 

Frequent  applications  of  tincture  of  iodin 
on  a  "tooth-pick"  swab  will  often  heal  a 
corneal  ulcer  where  other  means  fail. 

A  periostitis  at  the  margin  of  the  orbit  may 
resemble  a  cellulitis.  It  is  often  of  syphilitic 
origin. 

When  a  patient  complains  of  a  pain  in  the 
eye  with  epiphora,  don't  always  think  it  is 
due  to  conjunctivitis.  The  cause  may  be  a 
beginning  glaucoma. 

When  there  is  a  perforating  wound  of  the 
cornea,  necessitating  enucleation  of  the  eye, 
the  wound  should  be  closed  so  that  the  eye- 
ball does  not  collapse  during  the  operation. 

The  most  stubborn  and  inflamed  iris  will 
yield  and  the  pupil  dilate  if  a  leech  be  ap- 
plied just  back  of  the  lid-fissure,  and  a  small 
crystal  of  atropin  be  placed  in  the  conjunc- 
tival sac.     Avoid  systemic  poisoning  by  pres- 


21 


HEAD. 


sure  over  the  inner  canthus  with  the  tip  of 
the  finger,  occluding  the  tear-ducts  and  pre- 
venting the  atropin-laden  tears  from  running 
down  the  nose  and  being  swallowed. 


Marked  exophthalmos  with  a  purulent  iritis 
may  be  an  embolic  condition  (metastatic  cho- 
roiditis) due  to  septic  infection,  e.  g.,  of  the 
uterus,  as  after  an  induced  abortion. 


A  difi^use  swelling  of  the  orbit,  moderate 
exophthalmos,  intense  pain  and  tenderness 
and  marked  edema,  mean  an  infection  extend- 
ing deeply  into  the  orbital  planes.  Unless 
early  treatment  is  instituted,  the  eyesight  may 
be  lost,  or  the  infection  may  extend  along  the 
course  of  the  optic  nerve  resulting  in  menin- 
gitis or  sinus  thrombosis.  Wherever  there 
is  fluctuation,  early  incision  is  necessary;  and 
free  drainage  of  the  infected  area  is  of  para- 
mount importance. 

Wolfe  grafts  for  the  lids  or  for  an  artificial 
socket  must  be  made  very  large  to  allow  for 
shrinkage.  Allow  an  extra  half  inch  for  each 
inch  in  length  and  width  of  the  defect  to  be 
covered. 


22 


HEAD. 


In  prescribing  eye-drops,  order  a  dropper 
to  be  placed  in  the  bottle  in  place  of  a  cork, 
as  a  stopper.  It  will  always  be  at  hand  and 
always  clean,  and  the  solution  will  not  be 
contaminated. 

An  old  Beer's  knife  that  has  been  ground 
so  often  that  it  is  of  no  use  for  corneal  in- 
cisions is  excellent  for  opening  styes  or  cha- 
lazia, and  a  small  straight  keratome,  on  ac- 
count of  its  double  edge,  is  far  better  than 
any  scalpel  for  splitting  the  lid  margin  in 
entropion  and  trichiasis  operations. 

Avoid  bichlorid  of  mercury  solutions  in 
eye  work,  as  much  as  possible.  After  cocain 
has  been  used,  they  may  cause  a  permanent 
opacity  of  the  cornea. 

After  using  a  cocain  solution  on  the  eye, 
be  sure  to  keep  it  well  irrigated,  or  protected 
by  a  bland  ointment,  or  bandaged,  to  pre- 
vent drying  and  subsequent  erosion. 

After  iridectomy  for  glaucoma  the  pupil 
of  the  sound  eye  should  be  kept  contracted 
by  pilocarpin  for  at  least  a  week,  but  not 
bandaged,  for  it  should  be  open  to  frequent 
inspection. 


23 


HEAD. 


After  using  a  mydriatic  in  an  adult,  instil 
pilocarpin  I  %,  and  keep  the  patient  under 
observation  until  the  pupil  contracts. 

Test  the  vision  carefully  in  every  case  of 
ocular  injury,  even  if  it  is  apparently  noth- 
ing but  a  "black  eye." 

When  a  grey  or  blue  eye  turns  brown  and 
loses  sight,  after  an  injury,  one  may  be  al- 
most sure  of  the  presence  in  the  globe  of  a 
chip  of  steel  or  iron  that  is  slowly  rusting 
(siderosis). 

A  large  pupil  in  an  aged  patient  is  a  dan- 
ger signal,  suggesting  glaucoma  with  insidious 
onset. 

Nose.  Severe  pain   in   the   orbit  or  even  in   the 

eye  itself  should  make  one  think  of  frontal 
sinus  infection,  especially  if  there  is,  or  re- 
cendy  has  been,  a  nasal  discharge.  Marked 
localized  tenderness  will  soon  confirm  the 
suspicion,  if  the  disease  exist. 

A  diagnosis  of  supraorbital  neuralgia 
should  not  be  made  until  frontal  sinusitis 
has  been  carefully  excluded. 


24 


MEAD, 


A  persistent,  chronic  discharge  from  the 
nose  should  lead  one  to  suspect  chronic  dis- 
ease of  the  frontal  or  other  accessory  sinus. 


Transillumination  is  a  method  of  corrob- 
orative value  only  in  the  diagnosis  of  acces- 
sory nasal  sinus  disease.  By  itself  it  is  of 
small  diagnostic  use. 

If  a  patient  has  had  a  nasal  operation  per- 
formed, especially  if  the  accessory  sinuses 
have  been  operated  upon,  severe  frontal  head- 
aches may  mean  thrombosis  of  the  cavernous 
sinus,  even  if  no  fever  be  present. 

A  large  dose  of  antipyrin  or  quinin  w^ill 
often  clear  up  a  frontal  headache  due  to 
acute  catarrh  of  an  accessory  sinus,  by  its 
astringent  action  on  the  mucous  membrane 
and  the  consequent  improvement  of  drainage. 


In  every  case  of  injury  to  the  nose,  with  or 
without  fracture,  it  is  well  to  examine  the 
septum  for  displacement.  If  displaced,  it 
should  be  carefully  restored,  using  a  nasal 
plug,  if  necessary,  to  keep  it  in  place. 


25 


MEAD. 


When  paraffin  is  injected  in  the  treatment 
of  saddle-nose  pressure  should  be  made  at 
the  root  of  the  nose  and  on  both  sides,  to  pre- 
vent possible  embolism  or  the  escape  of  the 
mass  into  surrounding  tissues. 


Face.  Non-malignant  tumors  of  the  parotid  prac- 
tically never  cause  pressure  effects  on  the  fa- 
cial nerve.  This  may  be  of  importance  in 
differentiating  them  from  malignant  tumors. 


A  swelling  in  the  parotid  region  is  not 
necessarily  a  part  of  the  parotid  gland.  It 
may  be  an  infection  of  the  pre-auricular  lym- 
phatic gland.  Such  an  enlargement  may  be 
associated  with  herpes  of  the  forehead,  or  it 
may  be  part  of  a  chain  of  tuberculous  lymph 
glands. 


The  position  of  Steno's  duct  must  be  re- 
membered when  operating  upon  the  face. 


When  paraffin  is  injected  subcutaneously 
it  is  important  to  allow  for  increase  of  the 
size  of  the  mass  by  the  growth  of  connective 
tissue  around  it. 


26 


HEAD. 


In  chronic  osteomyelitis  of  the  jaw  it  is 
better  to  wait  months  for  a  sequestrum  to 
form  than  to  operate  a  dozen  times  for  the 
removal  of  necrosed  bone. 

All  swellings  of  the  lower  jaw  accom- 
panied by  a  discharging  fistula,  and  espe- 
cially if  there  be  multiple  fistulae,  should  be 
looked  upon  with  the  suspicion  of  actinomy- 
cosis until  proven  to  be  otherwise. 

A  tumor  in  the  soft  parts  of  the  cheek 
near  a  tooth  cavity  is  often  a  dentigerous  cyst. 

Syphilis  may  be  the  cause  of  a  small  tumor 
situated  in  the  masseter  muscle.  A  course 
of  mixed  treatment  should  always  be  resorted 
to  before  operation  is  decided  upon. 

If  a  frightened  or  refractory  child  will  not 
open  its  mouth,  pass  a  probe  between  two 
teeth  and  back  to  the  palate.  Instantly  the 
mouth  will  open  and  a  gag  may  be  slipped 
in. 

To  determine  how  soon  a  patient's  mucous 
membrane,  e.  g.,  of  the  mouth  or  urethra, 
becomes  insensitive   after  the   application  of 


riouth  and 
Pharynx. 


27 


cocain,  or  other  anesthetic,  the  surgeon  may 
employ  the  device  of  touching  a  little  of  the 
same  solution  to  his  own  tongue,  just  after 
the  application  to  the  patient. 

The  employment  of  adrenalin  as  an  ap- 
plication with  cocain  to  the  mucous  mem- 
brane of  the  cheek,  e.  g.,  for  the  excision  of 
a  leukoplakic  ulcer,  is  not  to  be  advised. 
There  may  be  severe  secondary  hemorrhage. 

When  there  is  bleeding  from  the  tongue, 
post-operative  or  otherwise,  and  one  feels 
reasonably  sure  that  the  hemorrhage  is  ar- 
terial, it  can,  as  a  rule,  be  easily  arrested  by 
passing  the  forefinger  down  to  the  epiglottis 
and  hyoid  bone  and  drawing  the  base  of 
the  tongue  upward  toward  the  chin. 

It  is  wrong  to  perform  any  radical  opera- 
tion for  an  ulcer  of  the  tongue  without  pre- 
liminary microscopical  examination.  Clinical 
symptoms,  no  matter  how  typical,  are  often 
misleading. 

A  deep  ulceration  of  the  fauces  or  tonsils 
should  not  be  diagnosed  as  specific  without 
excluding  acute  lymphatic  leukemia. 


28 


HEAD. 


The  blood  should  be  examined  in  all  cases 
of  gangrenous  gingivitis  for  evidences  of  acute 
lymphatic  leukemia. 

Before  operating  for  pharyngeal  adenoids 
or  hypertrophied  tonsils  make  sure  that  these 
are  not  merely  an  expression  of  status  lym- 
phaticus.  If  they  are,  do  not  employ  an 
anesthetic.  Also  determine  whether  the  pa- 
tient is  a  hemophiliac.  If  he  is,  do  not  oper- 
ate at  all. 


A  retropharyngeal  or  peritonsillar  swelling 
that  is  very  edematous  may  disappear  under 
the  administration  of  large  doses  of  salicy- 
lates. 

When  opening  a  retropharyngeal  or  peri- 
tonsillar abscess  in  a  small  child,  by  the 
buccal  route,  have  the  head  dependent  and 
instruments  at  hand  for  tracheotomy.  These 
instruments  are  needed  but  rarely,  but  then 
urgently. 

A  feeling  of  discomfort  in  the  mouth  while 
eating  may  be  the  first  sign  of  a  calculus  in 
one  of  the  salivary  ducts. 


29 


HEAD. 


Persistent  hemorrhage  after  the  extraction 
of  a  tooth  is  often  relieved  by  the  application 
of  trichloracetic  acid.  If  the  hemorrhage  does 
not  cease  after  its  application,  tamponade  of 
the  cavity  is  the  next  best  available  means  of 
stopping  the  flow  of  blood. 

Always  examine  a  child  suffering  from 
chorea  for  the  presence  of  adenoids.  The 
removal  of  the  growths  in  the  pharynx  may 
cure  a  mild  case. 


NECK. 


In  seeking  a  cause  for  torticollis,  don't  fail 
to  examine  the  teeth. 


In  all  cases  of  torticollis,  examine  for  caries 
of  the  spine. 

Perdiculosis  capitis  may  be  the  indirect 
cause  of  acute  torticollis  by  reason  of  a 
developing  post-cervical  adenitis. 

A  submaxillary  swelling  should  not  be  dis« 
missed  as  a  lymphatic  adenitis  without  study- 
ing Wharton's  duct  on  the  same  side.  Mas- 
sage of  pus  therefrom  would  demonstrate  a 
salivary  gland  inflammation,  probably  due  to 
the  presence  of  a  stone. 


30 


NECK. 


Examination  into  the  nature  and  cause  of 
discrete  hard  lympathic  swellings  on  each  side 
of  the  neck,  along  the  sterno-mastoid,  should 
include  exploration  of  the  pharynx  and  naso- 
pharynx for  possible  new  growth. 

In  all  glandular  affections  of  the  neck  it  is 
quite  as  important  to  treat  the  source  of  in- 
fection, e.  g.,  carious  teeth,  as  to  treat  the 
inflamed  glands. 

In  "Ludwig's  angina,"  the  cardinal  prin- 
ciple in  the  treatment  is  extensive  incision. 
An  incision  that  passes  no  matter  how  deep 
into  the  substance  of  the  submaxillary  gland 
proper,  will  prove  of  little  avail  unless  the 
tissues  within  the  wound  have  been  broken 
up  until  they  are  practically  pulpy. 

Have  the  tracheotomy  instruments  handy 
before  operating  upon  a  case  of  angina 
Ludovici. 

The  greatest  ultimate  danger  in  cut-throat 
cases  is  the  onset  of  a  septic  pneumonia.  This 
may  be  obviated  in  a  measure  by  closing  up 
the  pharyngeal  wall,  and  by  paying  the 
strictest  attention  to  asepsis. 


31 


NECK. 


In  cut-throat  wounds  where  the  thyro-hyoid 
membrane  has  been  severed,  it  is  necessary, 
in  order  to  restore  perfect  phonation  and 
deglutition,  to  suture  this  membrane  accu- 
rately. 


Avoid  the  use  of  peroxid  of  hydrogen  in 
wounds  of  the  neck.  It  is  too  apt  to  dissect 
up  the  loose  cellular  planes.  The  same 
warning  applies  in  many  cases  of  cellulitis 
of  the  hand  or  foot. 


In  the  presence  of  a  hard,  diffuse,  chronic 
swelling  in  the  neck  having  some  of  the  ap- 
pearances of  a  malignant  growth,  the  possi- 
bility that  the  tumor  is  a  so-called  "woody 
phlegmon  of  Reclus"  must  be  considered. 

Hard  subcutaneous  tumors  of  the  upper 
third  of  the  neck,  with  signs  of  malignancy, 
are  often  epitheliomata  arising  from  branchial 
clefts. 

An  exquisitely  tender  swelling  situated  just 
above  the  sterno-clavicular  articulation  may 
be  due  to  the  perforation  of  the  esophagus 
by  a  foreign  body.      If  there  are  evidences 


32 


MECK. 


of  acute  laryngitis,  with  edema  of  the  ary- 
tenoid cartilages,  the  cause  may  be  a  peri- 
chondritis of  one  of  the  tracheal  rings  or  the 
cricoid  cartilage. 

Any  enlargement  of  the  thyroid  gland  may 
cause  paralysis  of  one  of  the  vocal  cords 
by  pressure  on  the  recurrent  laryngeal  nerve 
or  may  impede  respiration  by  pressure  on 
the  trachea  itself.  But  a  laryngeal  examin- 
ation should  not  be  omitted,  for  the  whole 
trouble  may  be  caused  by  an  enlarged  acces- 
sory thyroid  on  one  of  the  vocal  cords. 

In  performing  operations  on  the  neck» 
make  the  skin  incision  parallel  to  the  muscu- 
lar  plane. 

Do  not  empty  a  thyro-glossal  cyst  by  as- 
piration before  extirpating  it.  It  is  well  to 
inject  the  cavity  with  a  methylene  blue  solu- 
tion first,  in  order  to  make  sure  that  all  parts 
of  the  cyst  wall  will  be  extirpated.  Another 
method  is  to  first  empty  the  cyst  and  then 
fill  it  with  paraffin. 

In  all  operations  in  the  left  subclavian 
triangle  of  the  neck,  the  location  there  of  the 
thoracic  duct  must  not  be  forgotten. 


33 


NECK. 


The  best  thing  to  do  in  such  emergencies 
as  air  embolism  is  to  apply  compression  im- 
mediately and  pour  large  quantities  of  solu- 
tion, preferably  salt  solution,  into  the  wound. 


Gradually  increasing  hoarseness  in  people 
past  middle  age,  without  definite  cause,  and 
with  a  history  of  pain  radiating  to  the  ear, 
is  suggestive  of  malignancy. 


After  an  operation  for  extensive  carbuncle 
of  the  neck,  a  comforting  support  may  be 
supplied  by  placing  under  the  bandage  a  piece 
of  heavy  manila  cardboard  (book-binders* 
board),  wetted  and  shaped  to  the  back  of 
the  head  and  neck. 


Tracheotomy. 


In  urgent  cases  a  high  tracheotomy  should 
l>e  performed,  not  a  low  tracheotomy.  The 
former  can  be  done  very  rapidly;  the  latter 
requires  considerable  dissection. 


The  best  site  for  an  urgent  tracheotomy  is 
through  the  crico-thyroid  membrane.  To 
hold  the  opening  apart  a  couple  of  hairpins, 
bent  at  the  end,  may  be  used  as  retractors. 


34 


INECK. 


In  the  performance  of  high  tracheotomy  a 
great  deal  of  room  can  be  gained  by  dividing 
transversely  the  fascia  that  extends  upward 
from  the  thyroid. 

After  tracheotomy  the  air  of  the  patient's 
room  should  be  kept  reasonably  warm  and 
moist.  Draughts  of  cold  air  provoke  much 
irritation. 

The  greatest  immediate  danger  after  a 
tracheotomy  is  the  possibility  of  a  subsequent 
pneumonia.  This  can,  in  a  large  measure, 
be  obviated  by  filtering  the  inspired  air 
through  a  soft  sponge  saturated  with  warm 
one  per  cent,  phenol  solution. 

Repeated  attacks  of  coughing  after  trache- 
otomy may  mean  irritation  of  the  posterior 
wall  of  the  trachea  by  the  tube;  change  the 
length  or  shape  of  the  canula. 


A  "tumor"  of  the  breast  occasionally 
proves  to  be  only  a  chronic  abscess.  It  has 
happened  that  a  breast  amputated  for  carci- 
noma has  been  found  to  be  the  seat  of  old 
abscesses  only. 


BREA5T. 


35 


BREA5T. 


In  the  treatment  of  a  breast  abscess  the 
size  of  the  incision  is  not  as  important  as  its 
location  and  direction. 

A  small  incision  and  the  proper  employ- 
ment of  a  Bier-Klapp  breast  cup  will  secure 
exceedingly  gratifying  results  in  many  cases 
of  mammary  abscess. 

In  the  presence  of  a  breast  infection  that 
fails  to  heal  within  a  reasonable  time  after 
appropriate  incision  and  dressings,  it  is  well 
to  think  of  local  tuberculosis. 


The  appearance  of  pus  in  the  breast  of  a 
woman  who  is  not,  or  has  not  recently  been 
nursing,  is  suspicious  of  some  unusual  form 
of  infection,  e.  g.,  tuberculosis. 

A  tender,  painful  swelling  just  at  or  be- 
yond the  upper,  outer  border  of  the  breast, 
and  near  the  edge  of  the  pectoralis  major, 
is  usually  an  inflamed  lymphatic  gland.  In 
its  presence  it  is  well  to  look  for  some  skin 
infection  about  the  waist  line,  e.  g.,  furuncles, 
which  are  not  rare  at  this  site  as  a  result  of 
irritation  by  the  corset.      Per  contra,  with  a 


36 


BREA5T. 


boil,  abscess,  dermatitis  or  other  infection  at 
or  above  the  waist  line,  one  may  be  on  the 
lookout  for  glandular  enlargement  at  the 
point  referred  to. 


In  the  performance  of  the  radical  oper- 
ation for  breast  carcinoma  it  is  important  to 
avoid  injury  to  the  periosteum  of  the  ribs. 

Multiplicity  of  tumors  of  the  breast  usu- 
ally speaks  against  carcinoma. 

Breast  tumors,  especially  in  the  early 
stages,  seldom  fail  to  present  the  classical 
signs  by  which  their  malignancy  or  non- 
malignancy  may  be  determined  clinically.  In 
all  cases  where  the  diagnosis  is  doubtful,  a 
specimen  of  the  tumor  should  be  removed  for 
microscopic  study,  before  undertaking  a  radi- 
cal operation. 

Involution  growths  in  the  breast  are  very 
often  cystic,  even  though  the  mass  appears  to 
the  feel  to  be  solid  throughout.  Carcino- 
matous degeneration  is  sometimes  found  in 
the  cyst  wall  of  these  originally  benign 
growths. 


37 


THOKAA. 


In  strapping  the  chest  for  fractured  rib, 
two  points  should  be  particularly  noted :  1 . 
The  straps  should  pass  well  beyond  the  me- 
dian line.  2.  They  should  be  applied  in 
full  expiration.  One  or  two  straps  passed 
over  the  shoulder  help  much  to  secure  im- 
mobilization. 

Cold  abscess  and  lipoma  often  simulate 
each  other  very  closely,  especially  around  the 
chest.     If  in  doubt,  aspirate. 

Do  not  be  too  hasty  in  making  a  diag- 
nosis of  intercostal  neuralgia.  With  the  ex- 
ception of  pulmonary  and  pleural  conditions, 
ulcer  of  the  stomach  simulates  intercostal 
neuralgia  more  frequently  than  any  other 
lesion. 

It  is  remarkable  how  frequently  a  puru- 
lent pericarditis  may  exist  without  causing 
many  or  severe  symtoms.  Never  neglect  an 
examination  of  the  cardiac  area,  therefore, 
in  cases  of  suspected  sepsis. 

When  a  patient  complains  of  dysphagia, 
do  not  neglect  to  examine  the  pericardium 
for  effusion. 


38 


THORAA. 


Care  must  be  taken  in  resecting  the  last 
true  rib  not  to  open  the  pleural  cavity;  for 
not  only  does  this  produce  a  pneumothorax, 
but  an  extensive  subcutaneous  empyhysema 
may  also  result. 

A  history  of  attacks  with  symptoms  of 
esophageal  stricture  and  intervening  periods 
of  well-being  is  suggestive  of  cardiospasm. 

A  satisfactory  method  of  x-ray  study  of 
esophageal  diverticula  and  strictures  con- 
sists in  fluoroscopy  of  the  thorax  while  the 
patient  is  swallowing  an  emulsion  of  bismuth 
subnitrate.  A  skiagraph  may  be  made  im- 
mediately afterwards  as  a  supplementary 
record. 

Before  operating  for  sarcoma  examine  the 
lungs  carefully.  Do  not  operate  if  the  pa- 
tient has  persistent  cough  and  blood-stained 
sputum  (not  due  to  tuberculosis),  even 
though  no  definite  signs  are  found  in  the 
lungs — a  metastasis  has  developed. 

A  fluctuating  swelling  appearing  between 
the  ribs  may,  of  course,  be  tuberculous  or 
syphilitic  in   origin,   but  it  may   also   be   an 


39 


TliORAA. 


extension  of  an  intrathoracic  growth,  e.  g., 
dermoid  cyst  of  the  mediastinum.  In  all  such 
cases,  threefore,  a  careful  examination,  by 
auscultation  and  percussion,  should  be  made. 


Clear  fluid  in  the  pleural  cavity  is  not  al- 
ways indicative  of  lung  or  pleural  disease.  It 
may  be  due  to  a  new  growth  of  the  medi- 
astinum pressing  upon  the  venae  cavae. 


A  mediastinal  tumor  may  be  present  for 
some  time  without  other  symptoms  than 
cough,  expectoration,  loss  of  flesh  and  slight 
fever — thus  simulating  pulmonary  tubercu- 
losis. A  skiagraph  will  determine  the  condi- 
tion; largynoscopy  is  also  helpful  for  ad- 
ductor paralysis  is  frequently  an  early  sign. 

A  slender  fish  bone  lodged  in  a  bronchus 
will  usually  not  cast  a  shadow  on  the  x-ray 
plate.  In  such  a  case  bronchoscopy  and  aus- 
cultation are  more  reliable  diagnostic  mea- 
sures. In  addition  to  a  variety  of  moist 
rales,  one  may  hear,  associated  with  the  in- 
spiratory or  expiratory  murmur,  or  both,  a 
musical  or  vibratory  note,  when  a  bone  or 
pin  lies  in  a  bronchus. 


40 


THOUAA. 


If  a  patient  dates  irregular  or  persistent 
cough  from  a  time  when  he  thinks  he  * 'swal- 
lowed" or  inspired  a  foreign  body,  the  fact 
that  the  physical  signs  elicited  upon  examina- 
tion of  the  chest  are  peculiar — different  from 
those  found  in  ordinary  types  of  bronchitis 
— points  strongly  to  the  presence  of  a  for- 
eign body. 


Bronchiectasis  is  not  rarely  complicated 
by  brain  abscess. 

The  chief  causative  factors  in  peripleuritic 
abscesses  are  actinomycosis  and  typhoid  osteo- 
myelitis. A  careful  history  as  to  a  previous 
typhoid  and  a  thorough  microscopic  examin- 
ation of  the  pus  should  be  secured. 


A  peripleuritic  abscess  due  to  caries  of  a 
rib  may  give  all  the  signs  and  symptoms  of 
an  encapsulated  empyema.  Aspiration  of  the 
chest  usually  withdraws  clear  fluid  (an  effu- 
sion due  to  the  inflammatory  process).  A 
positive  diagnosis  can  be  made  only  by  ex- 
ploration of  the  abscess  cavity,  when  a 
necrosed  rib  may  be  found  overlying  a  thick- 
walled  abscess  cavity. 


41 


THORAA. 


If  the  physical  signs  of  pneumonia  persist 
for  an  excessively  long  period,  especially  in 
children,  it  is  wise  to  aspirate  on  the  suspicion 
of  empyema. 

In  aspirating  the  chest,  see  to  it  that  the 
syringe  is  in  good  condition  before  inserting 
the  needle.  Never  apply  the  syringe  to  the 
needle  after  the  latter  has  been  inserted;  a 
severe  pneumothorax  may  result.  If  the 
syringe  is  found  to  be  out  of  order  while 
the  aspiration  is  being  done,  withdraw  the 
needle  also  and  reinsert. 

There  is  one  point  that  must  always  be 
thought  of  when  pus  has  been  aspirated  after 
an  exploratory  puncture  for  either  suspected 
empyema  or  liver  abscess, — to  make  sure 
that  the  *'pus"  does  not  come  from  a  bron- 
chus. This  can  be  determined,  as  a  rule,  by 
microscopical  examination  of  the  aspirated 
fluid. 

Very  extensive  and  rapidly  spreading  sub- 
cutaneous infections  may  result  after  an  aspi- 
ration of  a  foul-smelling  empyema.  It  is 
therefore  wise  to  always  operate  over  the 
site  of  aspiration,  and  especially  to  see  that 
the  puncture  wound  is  well  drained. 


42 


THORAA. 


When  operating  for  empyema  thoracis  it 
is  a  good  rule  to  asiprate  again  when  the 
pleura  is  exposed  and  before  it  is  incised. 
This  may  save  some  embarrassment. 

The  shock  of  evacuating  an  empyema  tho- 
racis may  be  largely  avoided  by  making  but 
a  small  opening  in  the  pleura  (after  resect- 
ing the  rib)  and  applying  at  once  several 
thickness  of  gauze.  At  the  next  dressing 
much  or  most  of  the  pus  will  be  found  to 
have  escaped  into  the  gauze,  and  the  pleural 
wound  may  then  be  enlarged  without  produc- 
ing shock. 

After  operation  for  empyema,  a  cover  of 
oiled  silk  or  gutta-percha  over  the  gauze 
dressing  serves  to  prevent  admission  of  air 
into  the  pleural  cavity,  while  it  will  not  in- 
terfere with  the  escape  of  air  already  in 
the  chest.  Indeed,  a  flap  of  rubber  may  be 
laid  over  the  wound  and  fastened  with  a 
little  chloroform  above.  This  allows  pus 
to  escape  from  beneath  it  and  excludes  the 
admission  of  air. 


It  is  surprising  how  much  information  can 
be  derived  by  abdominal  palpation  conduct- 
ed with  the  patient  in  a  hot  bath,  the  temper- 


ABDOriEN. 


43 


ABDOriEN. 


ature  of  the  water  being  gradually  raised  to 
105°  F.  It  usually  secures  as  much  relaxa- 
tion as  does  the  administration  of  an  anes- 
thetic, sometimes  even  more.  In  addition  to 
the  avoidance  of  the  dangers  and  the  dis- 
agreeable features  of  narcosis,  it  has  the  im- 
portant advantage  that  the  patient  is  able  to 
call  the  examiner's  attention  to  sensitive  areas. 

In  the  presence  of  a  tumor  in  the  mid- 
line between  umbilicus  and  pubes,  the  pos- 
sibility of  a  cyst  of  the  urachus  must  be 
borne  in  mind.  It  may  simulate  an  ovarian 
cyst  or  other  tumor,  or  a  distended  bladder. 

Eczema  of  the  umbilicus  is  sometimes 
merely  the  expression  of  an  infected  dermoid 
cyst  at  that  site. 

A  discharge  from  the  umbilicus  may  be 
due  to  an  infected  dermoid  cyst,  to  an  ec- 
zema of  the  umbilicus,  to  a  patent  urachus 
(urine),  to  a  cyst  of  the  urachus  (milky 
discharge)  ;  it  may  be  of  pus  from  an  ab- 
scess within  the  abdomen  or  in  the  abdom- 
inal wall,  or  of  feces  (Meckel's  diverticulum, 
perforated  strangulated  hernia,  fecal  abscess 
from  tuberculosis). 


44 


ABDOriEIN 


Do  not  ligate  tumors  of  the  navel  without 
making  sure  that  the  intestine  is  not  included 
within  the  ligature. 

In  performing  paracentesis  in  the  median 
line  for  abdominal  fluid,  be  sure  that  the 
bladder  is  empty.  When  it  is  necessary  to 
perform  paracentesis  in  the  lateral  part  of  the 
abdomen,  be  careful  to  avoid  the  deep  epi- 
gastric artery. 

Unless  some  other  cause  is  evident  don't 
fail  to  examine  for  signs  of  tabes  when  an 
adult  complains  of  pains  about  the  waist,  in 
the  back  or  in  the  lower  extremities. 

Children  who  complain  frequently  of  pain 
in  the  stomach  should  be  examined  for  evi- 
dence of  beginning  Pott's  disease.  Such 
cases,  treated  before  the  development  of  cur- 
vature, usually  yield  very  satisfactory  results. 

In  all  cases  of  acute  abdominal  pain,  never 
fail  to  examine  the  lungs  and  gums.  The 
onset  of  pneumonia  or  pleurisy  frequently 
closely  simulates  acute  appendicitis;  lead 
colic  may  simulate  almost  any  painful  ab- 
dominal condition. 


45 


ABDOMEN. 


Enlargement  of  the  veins  at  the  side  of  the 
abdomen  is  indicative  of  obstruction  to  the 
flow  of  blood  in  the  inferior  vena  cava;  dis- 
tention of  veins  about  the  umbiHcus  sug- 
gests obstruction  in  the  portal  circulation. 
The  former  may  be  associated  with  varices 
of  the  lower  extremities,  the  latter  with 
hemorrhoids. 

In  all  cases  of  recurrent  vomiting  examine 
the  midline  of  the  abdomen  for  a  small  epi- 
gastric hernia. 

Catheterization  sometimes  makes  the  evi- 
dences of  "appendicitis"  or  "abdominal  tu- 
mor" vanish  with  the  escape  of  the  urine 
from  a  distended  bladder. 

In  cases  of  run-over  by  vehicles,  if  the 
wheels  pass  over  the  trunk  from  right  to 
left  the  liver  is  the  organ  most  commonly 
ruptured,  whereas,  if  the  wheels  pass  from 
left  to  right  the  spleen  is  more  frequently 
injured. 

The  hypodermatic  injection  of  eserin 
(salicylate)  gr.  1/30 — 1/40,  during  or  just 
after  an  abdominal  operation,  will,  in  most 


46 


ABDOMEN 


cases,  entirely  or  largely  prevent  the  distress- 
ing tympanites  that  otherwise  usually  occurs. 

A  pulsating  swelling  in  the  midline  of  the 
abdomen  should  not  be  too  quickly  accepted 
as  an  aneurism  of  the  aorta.  It  may  be  a 
retroperitoneal  tumor. 


In  the  presence  of  large  masses  of  glands 
in  the  epigastrium,  especially  on  the  right 
side,  examine  the  testicles  for  new  growth. 


Large,  slowly  growing,  slightly  movable 
abdominal  tumors  near  the  median  line,  caus- 
ing few  symptoms  and  not  accompanied  by 
signs  of  malignancy,  are  suggestive  of  mesen- 
teric cysts. 


A  primary  tumor  of  the  lateral  abdomi- 
nal region  in  infants  and  young  children  is 
usually  a  sarcoma  of  the  kidney. 

In  operating  for  perforating  gun-shot 
wounds  of  the  abdomen,  find  the  source  of 
any  bleeding  first,  before  attempting  to  suture 
any  perforation. 


47 


ABDOriEN. 


In  suturing  the  fascial  layers  of  the  ab- 
dominal wall  do  not  take  too  large  bites 
with  the  needle.  Necrosis  may  occur,  and 
sloughing  of  the  fascia  predisposes  to  the 
formation  of  hernia. 

If  there  is  repeated  vomiting  and  the  pa- 
tient shows  some  evidences  of  collapse,  after 
a  laparotomy,  especially  after  operation  in 
the  gastric  region,  examine  for  separation  of 
the  wound  and  prolapse  of  the  abdominal 
contents. 

In  children,  in  cases  of  peritonitis  of  un- 
known origin,  examine  for  gonorrheal  vulvo- 
vaginitis. 

A  boggy,  tender  abdomen  is  often  sugges- 
tive of  a  pneumococcus  peritonitis.  A  care- 
ful inquiry  as  to  a  previous  pneumonia  or  em- 
pyema is  most  important. 

The  presence  of  an  indefinite  mass  in  the 
abdomen  of  a  child  running  intermittent  tem- 
peratures may  mean  a  tuberculous  peritonitis. 

A  condition  of  euphoria  is  often  seen  in 
serious  cases  of  peritonitis  and  should  not  be 
taken  as  a  sign  of  beginning  recovery. 


48 


ABDOriEIN 


A  diagnosis  between  a  tumor  anterior  to 
the  rectus  muscle  and  a  tumor  more  deeply 
seated,  can  be  made  by  grasping  the  tumor 
and  then  having  the  patient  rise  from  the 
recumbent  to  the  sitting  posture.  Tumors 
anterior  to  the  rectus  muscle  do  not  escape 
from  the  grasp  of  the  fingers  during  this 
maneuver,  while  tumors  behind  the  muscle 
cannot  be  firmly  held. 

Steady  loss  of  weight  without  other  de- 
monstrable cause  should  lead  the  physician 
to  look  for  a  possible  malignant  visceral  neo- 
plasm. Persistent  "indigestion"  due  to  some 
condition  not  positively  ascertained,  should  be 
submitted  to  surgical  diagnosis. 


Excellent  results  may  be  obtained  in  liver 
abscess  cases  (solitary  abscesses) ,  which 
drain  for  a  long  time,  by  applying  a  Bier 
cup  over  the  superficial  opening  once  a  day 
for  five  minutes.  One  must  be  especially 
cautious  in  these  cases  not  to  increase  the 
vacuum  too  rapidly  as  rupture  of  the  vessels 
in  the  liver  might  easily  ensue  and  cause  seri- 
ous damage. 


Bile  Tract. 


There   is   such   a   condition    as   idiopathic 
swelling   of   the   liver — an    acute   hepatitis — 


49 


ABDOriEN. 


due  to  an  unknown  cause.      The  condition 
gradually  subsides  without  treatment. 

Repeated  attacks  of  "indigestion,"  not  ob- 
viously due  to  some  other  condition,  should 
awaken  the  suspicion  of  gall-stones.  Most  of 
the  patients  operated  upon  for  cholelithiasis 
give  a  history  of  having  been  treated  for  a 
long  time  for  "dyspepsia,"  and  in  many  of 
these  cases  the  correct  diagnosis  might  ear- 
lier have  been  established. 

If  pressure  in  the  right  hypogastrium  gives 
rise  to  a  referred  pain  in  the  shoulder  region, 
the  offending  area  is  probably  the  gall- 
bladder and  not  the  pylorus. 

In  an  attack  of  cholelithiasis  the  vomiting 
as  a  rule  is  not  attended  by  relief  of  pain; 
the  contrary  is  true  in  ulcer  of  the  stomach. 

In  differentiating  between  gastric  ulcer  and 
gall-stone  pains,  the  assocation  of  a  chill  usu- 
ally points  to  cholelithiasis. 

If  one  suspects  acute  cholecystitis  and  on 
opening  the  abdomen  does  not  find  the  gall- 
bladder enough  diseased  to  warrant  further 


50 


ABDOriEIN. 


procedure,  it  may  be  well  to  anchor  the 
organ  by  suturing  it  to  the  abdominal  wall. 
If  further  symptoms  are  manifested,  the  gall- 
bladder can  then  be  opened  without  anes- 
thesia and  a  catheter  inserted  for  drainage. 

Tenderness  over  the  gall-bladder  region, 
especially  if  accompanied  by  colicky  pain, 
usually  means  a  pathological  condition  of  that 
organ.  But  an  inflamed  retrocecal  appendix 
extending  high  up,  hydronephrosis,  acute 
pancreatitis,  and  an  inflammatory  condition  at 
the  pyloric  end  of  the  stomach  are  also  to  be 
kept  in  mind. 

Tuberculosis  and  cholelithiasis  are  only 
very  rarely  associated. 

Long  pauses  between  attacks  of  gastric 
or  abdominal  pain  speak  in  favor  of  chole- 
lithiasis. 

In  the  progress  of  a  cholecystectomy,  if  a 
stone  slips  away  after  cutting  through  the 
cystic  duct,  and  cannot  be  found,  no  great 
anxiety  need  be  felt,  for  the  stone  usually 
comes  away  spontaneously  in  the  subsequent 
discharge. 


51 


ABDOriEIN. 


Moderate  bloody  discharge  after  extirpa- 
tion of  the  gall-bladder,  is  most  often  due  to 
oozing  from  the  raw  surface  of  the  liver. 
Sudden,  profuse,  bloody  discharge  is  more 
dangerous,  for  it  means  that  the  ligature  has 
slipped  from  the  cystic  artery. 

Great  pain  following  any  operation  upon 
the  biliary  tract  should  always  lead  one  to 
suspect  leakage  of  bile  into  Morrison's  space. 
If  such  should  be  found  to  be  the  case  insert 
a  drainage  tube. 

When  operating  for  cholelithiasis,  don't 
fail  to  examine  the  hepatic  duct. 

When  palpating  the  common  bile  duct  for 
stone,  make  sure  that  a  suspected  calculus 
is  not  a  gland. 

In  catarrhal  icterus  the  pulse  is  usually 
slow;  in  jaundice  from  cholelithiasis  this  is 
usually  not  the  case. 

Gradually  increasing  jaundice  without 
previous  history  of  pain,  or  with  a  history 
of  very  slight  pain,  is  very  suggestive  of 
malignant  disease. 


52 


Before  attributing  enlargement  of  the  liver 
to  a  surgical  condition  exclude  chronic  hep- 
atic congestion  of  cardiac   disease. 

Examine  the  rectum  in  all  cases  of  tumor 
of  the  liver.  Likew^ise,  before  operating  for 
cancer  of  the  rectum  examine  the  liver  for 
metastasis. 


ABDOriEIN, 


Examination  to  determine  the  possible 
presence  of  cardiac  disease  or  aneurism 
should  always  be  made  before  passing  a 
stomach  tube.  In  the  presence  of  such  le- 
sions the  tube  should  not  be  employed  ex- 
cept as  a  life-saving  measure  in  an  emer- 
gency. 


stomach. 


A  hasty  diagnosis  of  ulcer  of  the  stomach 
should  not  be  made  merely  because  the  pa- 
tient has  vomited  suddenly  large  quantities 
of  blood.  If  the  bleeding  occurs  at  regular 
intervals  the  possibility  of  vicarious  menstru- 
ation must  be  considered. 


The  occurrence  after  laparotomy  of  mark- 
ed distention  of  the  upper  abdominal  zone, 
vomiting  and  collapse,  points  to  acute  dila- 
tation of  the  stomach. 


53 


ABDOriEN. 


It  is  well  to  remember  that  not  all  ulcers 
of  the  stomach  are  characterized  by  the 
classical  symptoms  of  pain,  vomiting  and 
hemorrhage.  Many  patients  presenting 
"dyspeptic"  symptoms  of  only  mild  grade 
are  afflicted  with  this  disease,  and  such  cases 
may  easily  be  diagnosed  as  functional  dis- 
orders until  the  persistence  of  the  symptoms 
leads  one  to  suspect  the  graver  malady. 


The  thirst  following  a  hemorrhage  from 
gastric  ulcer  is  best  relieved  by  small  quan- 
tities of  cocain  in  solution. 


If  an  undoubted  case  of  ulcer  of  the  stom- 
ach is  associated  with  chills,  in  most  cases  it 
means  that  the  ulcer  is  adherent  to  the  spleen. 

A  sudden  desire  for  sharp,  sour  and  spicy 
articles  of  food  in  a  middle-aged  or  elderly 
person  is  often  the  first  symptom  of  a  be- 
ginning gastric  carcinoma. 

In  a  case  of  gastric  disease  of  doubtful 
diagnosis,  progressive  loss  of  weight  is  the 
most  important  sign  in  determining  the  prob- 
ability of  carcinoma. 


54 


ABDOriEN 


The  possibility  of  gastric  cancer  must  be 
considered  in  cases  of  supposed  pernicious 
anemia. 

In  persons  of  middle  age  presenting  gas- 
tric symptoms,  the  diagnosis  of  cancer  should 
not  be  excluded  because  the  symptoms  have 
had  a  sudden  onset.  Such  an  onset  occurs  in 
a  fair  proportion  of  cases. 

Vomiting,  secondary  anemia  and  absence 
of  free  hydrochloric  acid  in  the  gastric  juice 

a  triad  of  symptoms  at  once  suggestive  of 

carcinoma  ventriculi — may  occur  as  a  result 
of  chronic  nephritis.  Especially  if  the  urine 
contain  no  casts  or  albumin  is  the  observer 
apt   to   be  led   astray. 

If  a  patient  vomits  coffee-ground  material 
in  which  no  lactic  acid  is  present,  one  can 
almost  always  exclude  carcinoma. 

A  reasonable  suspicion  of  the  presence  of 
a  cancer  in  the  stomach  or  intestine  is  suffi- 
cient indication  for  explorative  operation. 

Before  proceeding  with  a  radical  operation 
for  carcinoma  of  the  stomach,  examine  not 
only  the  liver  but  also  the  general  abdominal 


55 


ABDOriEIN. 


cavity,  especially  the  pelvis,  and  in  females 
the  ovaries,  for  any  sign  of  metastasis. 

Do  not  be  too  sure  that  a  mass  in  the  re- 
gion of  the  pylorus  is  a  carcinoma.  In  some 
cases  the  infiltration  around  a  chronic  ulcer 
is  very  extensive  and  may  simulate  the  feel 
of  a  new  growth. 

If  a  patient  begins  to  vomit  long  after  a 
radical  operation  for  carcinoma  of  the  stom- 
ach, do  not  jump  to  the  conclusion  that  the 
cause  is  a  local  recurrence.  It  may  be  a 
metastasis  in  the  brain. 

In  a  patient  with  spondylitis,  symptoms 
simulating  acute  peritonitis  may  be  due  to 
acute  dilatation  of  the  stomach. 

The  occurrence  after  laparotomy  of  marked 
distention  of  the  upper  abdominal  zone,  vom- 
iting and  collapse  points  to  acute  dilatation 
of  the  stomach. 

It  is  a  peculiar  fact  that  post-operative 
prolapse  through  the  epigastric  wound  occurs 
frequently  in  operations  for  malignant  disease 
of  the  stomach.  Such  wound  therefore  should 


56 


ABDOriEN 


be  closed  with  more  than  usual  firmness  and 
all  possible  precautions  should  be  taken  to 
guard  against  post-operative  vomiting. 

In  performing  posterior  gastro-enterostomy 
see  that  the  opening  in  the  transverse  meso- 
colon is  not  so  narrow  that  it  may  constrict 
the  anastomosed  segment  of  small  intestine 
nor  yet  so  large  that  it  may  permit  of  a 
possible  hernia  into  the  lesser  sac.  By  in- 
serting a  number  of  sutures  between  the  meso- 
colon and  the  stomach  wall  about  the  anas- 
tomosis these  possibilities  may,  in  large  part, 
be  obviated. 

If  within  a  week  or  two  after  the  perfor- 
mance of  gastrostomy  the  drainage  tube 
should  be  expelled  from  the  fistula,  do  not 
entrust  its  re-introduction  to  inexperienced 
hands.  It  has  sometimes  happened  that  the 
tube  has  been  pushed  into  the  peritoneal 
cavity,  instead  of  into  the  stomach. 


In  the  presence  of  anemia  or  of  faintness, 
without  other  apparent  cause,  inquire  con- 
cerning the  passage  of  black  stools.  The 
condition  may  result  from  hemorrhages  due 
to  an  ulcer  or  neoplasm  of  the  small  intes- 
tine. 


Intestines. 


57 


ABDOriEIN. 


A  gradually  increasing  anemia  in  an  eld- 
erly person,  without  any  other  symptoms,  is 
highly  suggestive  of  a  latent  carcinoma,  often 
in  the  intestine. 

In  typhoid  fever  spontaneous  rupture  of 
the  spleen  may  simulate  intestinal  perforation. 

The  triad  of  symptoms — ^pain,  vomiting 
and  distention — ^without  fever,  points  to  in- 
testinal obstruction. 

Attacks  of  abdominal  pain  preceded  by 
"rumbling"  of  the  bowels  is  suggestive  of 
some  obstructive  condition. 

The  passage  of  a  small  amount  of  gas 
or  even  of  feces,  after  an  enema,  does  not 
gainsay  the  presence  of  intestinal  obstruction. 

In  an  acute  condition  simulating  intesti- 
nal obstruction,  if  a  large  mass  can  be  felt  in 
the  abdomen  think  of  omental  torsion. 

In  acute  intestinal  obstruction  it  is  often 
preferable  to  relieve  the  immediate  danger  to 
life  by  tentative  enterostomy  or  colostomy 
than  to  hunt  for  the  cause  of  the  obstruction. 


58 


ABDOriEN. 


Simple  or  multiple  enterostomy,  usually 
with  prompt  suture  of  the  opening,  is  many 
times  a  life-saving  operation  in  the  presence 
of  intestinal  paresis,  as  from  general  periton- 
itis. 

Post-operative  acute  intestinal  obstruction 
in  rare  instances  has  for  its  causation  an  in- 
terstitial hernia  through  the  abdominal  w^all. 
A  mass  composed  of  confined  gut  is  usually 
present. 

An  attack  of  acute  intestinal  obstruction, 
vvrith  passage  of  blood,  and  in  the  presence 
of  a  cardiac  lesion,  is  suggestive  of  throm- 
bosis of  a  mesenteric  vessel. 

Every  case  of  intestinal  obstruction  of  ob- 
scure origin  should  be  inquired  into  closely 
with  reference  to  a  previous  history  of  chole- 
lithiasis. If  a  definite  history  of  this  is  ob- 
tained, one  may  suspect  obstruction  by  a 
gall-stone. 

When  operating  for  volvulus  of  the  large 
intestine,  insert  a  rectal  tube  as  high  up  as 
possible  before  attempting  the  reduction.  The 
volvulus  will  quickly  collapse  and  the  neces- 
sity for  evisceration  will  thus  be  avoided. 


59 


ABDOMEN. 


In  infants  sudden,  severe  colic  associated 
with  diarrhea  or  the  passage  of  small  quan- 
tities of  blood,  should  lead  one  strongly  to 
suspect  an  intussusception. 

When  reducing  an  intussusception  don't 
pull  on  the  intussusceptum  but  push  on  the 
intussuscipiens. 

When  a  patient  gives  all  the  signs  and 
symptoms  of  appendicitis,  if  the  stools  have 
been  noticeably  black,  a  duodenal  ulcer 
should  be  kept  in  mind. 

A  perforated  intestinal  ulcer,  especially  if 
low^  down,  may  simulate  acute  appendicitis. 
A  very  high  leucocyte  count  with  a  high 
percentage  of  polynuclears,  and  the  presence 
of  a  large  amount  of  fluid  in  the  peritoneal 
cavity,  accompanied  by  general  rigidity,  may 
suggest  the  diagnosis. 

A  palpable  tumor  in  the  umbilical  region 
is  often  a  malignant  growth  of  the  transverse 
colon.  Benign  growths  of  the  mesentery  are 
also  found  here. 


A  mesenteric  cyst  may  give  the  same  signs 
as   a  small   ovarian  cyst.     Mesenteric  cysts, 


60 


ABDOMEPS. 


although  movable,  are  usually  attached  to  the 
ascending  colon.  When  the  colon  is  dilated 
a  direct  relation  can  be  made  out  between  the 
gut  and  the  tumor. 

The  presence  of  a  tumor  of  the  sigmoid 
flexure  with  symptoms  of  chronic  obstruction 
does  not  always  indicate  a  cancer.  Such  a 
condition  may  be  due  to  a  "diverticulitis." 

A  fecal  fistula  may  be  made  to  heal  more 
quickly  by  the  application  of  the  actual 
cautery. 

In  the  presence  of  a  movable,  sausage- 
shaped  mass  in  the  abdomen,  with  a  his- 
tory of  chronicity,  it  is  well  to  think  of  the 
possibility  of  its  being  a  case  of  hyperplastic 
tuberculosis  of  the  intestine.  This  diagnosis 
will  be  rendered  more  likely  if  there  are 
definite  signs  in  the  lungs. 

At  the  onset  of  an  attack  of  acute  appen-     Appendix, 
dicitis  the  pain  is  usually  referred  to  the  gas- 
tric region. 

The  cessation  of  severe  pain  during  the 
course  of  acute  appendicitis  often  means  per- 
foration. 


6r 


ABDOIiEIN. 


The  twisting  of  the  pedicle  of  an  ovarian 
cyst  may  simulate  both  the  symptoms  and 
signs  of  attacks  of  appendicitis. 

A  moderately  hard,  palpable  mass  in  the 
right  iliac  region  is  often  diagnosed  as  acute 
appendicitis  with  inflamed  omentum  around 
the  appendix.  But  ileocecal  tuberculosis  with 
inflammatory  exudate  should  be  kept  in  mind. 

The  tenderness  in  appendicitis  may  not  be 
(probably  usually  is  not)  just  at  McBurney's 
point.  The  base  of  the  appendix  is,  however, 
usually  at,  or  near,  that  point.  The  site  of 
greatest  tenderness  is  often  over  the  tip  of  the 
appendix.  A  line  drawn  between  that  site 
and  McBurney's  point  will  many  times  repre- 
ent  the  general  direction  in  which  the  appen- 
dix is  lying. 

In  cases  of  chronic  appendicitis,  if  an  ex- 
amination be  conducted  with  the  patient  in 
a  hot  bath  ( 1 05  °  F. ) ,  the  thickened  appen- 
dix may  often  be  felt  to  roll  under  the  finger. 

The  location  of  the  Head  zone  will  often 
decide  whether  a  case  is  one  of  acute  appen- 
dicitis with  inflammation  of  the  serosa  or 
acute  salpingitis.       If  the  Head  zone  com- 


62 


ABDOriEN, 


mences  at  the  level  of  the  umbilicus,  extends 
over  to  the  right  lumbar  region  and  to  just 
below  Poupart's  ligament,  it  is  probably 
acute  appendicitis.  If  the  Head  zone  begins 
two  or  three  inches  below  the  umbilicus  with 
a  broad  base  on  the  abdomen  and  extends  to 
a  single  point  midway  between  the  hip-joint 
and  the  knee,  the  case  is  probably  one  of 
acute  salpingitis. 

In  a  case  of  appendicitis,  there  is  great 
significance  in  the  disappearance  of  a  Head 
zone  which  had  been  present  but  a  few 
hours  before.  It  means  that  the  tension  on 
the  serosa  of  the  appendix  has  lessened.  The 
natural  conclusion  to  draw  is  that  the  appen- 
dix has  ruptured. 

Sudden,  marked  rise  of  temperature  a  few 
days  after  an  operation  for  appendicitis,  espe- 
cially if  attended  by  chills,  may  mean  throm- 
bosis of  the  portal  vein,  multiple  abscesses 
of  the  liver,  or  subphrenic  abscess. 

If  there  is  a  sudden  rise  of  temperature 
after  appendicectomy,  examine  the  rectum. 
A  bulging  of  the  wall  of  the  rectum  on  the 
right  side  or  anteriorly  indicates  the  forma- 
tion of  a  pelvic  abscess. 


6-. 


ABDOriEN. 


A  persistent  sinus  after  an  operation  for 
appendicitis  in  the  majority  of  cases  means 
that  a  portion  of  the  appendix  has  been  left 
behind.  It  may  also  mean  that  an  exudate 
has  not  broken  down  or  that  some  foreign 
body  has  been  left  in  the  wound.  One  should 
give  the  sinus  an  opportunity  to  close  by  itself, 
but  if  it  does  not  do  so,  a  prolonged  opera- 
tion is  necessary.  The  walls  of  the  sinus 
must  be  carefully  excised,  all  rents  in  the 
serosa  of  the  intestine  sewed  over  and  drain- 
age instituted,  as  there  is  often  considerable 
oozing  from  raw  surfaces.  First  and  fore- 
most, the  primary  cause  of  the  sinus  must  be 
found  and  corrected. 


HERNIA. 


It  is  a  wise  rule  never  to  attempt  taxis 
in  cases  of  strangulated  hernia.  The  only 
exception  might  possibly  arise  in  a  case  seen 
within  the  first  hour. 


All  cases  of  hernia  in  which  there  is  a 
history  of  frequent  urination  should  lead  one 
to  the  suspicion  that  the  hernial  sac  contains 
part  of  the  bladder. 

A  properitoneal  epigastric  hernia  may  give 
no  external  signs.  The  patient  merely  com- 
plains of  pain  in  the  epigastrium. 


64 


HERNIA. 


An  inguinal  hernia  giving  signs  of  obstruc- 
tion and  partially  reducible,  may  empty  into 
a  properitoneal  sac  in  Hesselbach's  triangle, 
a  loop  of  gut  being  compressed  against  the 
neck  of  the  sac. 

In  cases  of  strangulated  hernia  a  simple 
enterostomy  after  cutting  the  neck  of  the  sac 
will  often  save  a  life  where  a  prolonged  oper- 
ation would  result  in  death. 

If  a  peculiar  looking  mass  is  found  at  the 
inner  side  of  the  ring  in  the  course  of  an 
operation  for  inguinal  hernia,  do  not  incise 
or  dissect  it  before  convincing  yourself  that 
it  is  not  the  bladder. 


Probably  the  most  important  step  in  radi- 
cal inguinal  hernioplasty  is  the  total  removal 
of  the  sac.  It  should  be  traced  back  to  the 
loose  peritoneum  itself,  exposing  the  deep  epi- 
gastric vessels,  the  ligature  or  sutures  to  be 
applied  at  that  level.  To  leave  even  a  little 
projecting  knuckle  of  peritoneum  invites  re- 
currence. 

Do  not  be  too  hasty  in  resecting  a  strangu- 
lated loop  of  intestine.     It  is  remarkable  how 


65 


HERNIA. 


frequently  such  loops  become  viable  after 
long  continued  applications  of  hot  saline  so- 
lution. 


If  the  sutures  in  a  hernioplasty  are  tied  too 
tight  or  too  near  together,  a  distressing  in- 
duration of  the  issues  will  often  take  place. 
This  may  be  relieved  by  opening  up  the  lower 
angle  of  the  wound  so  as  to  let  out  the  serum 
between  the  different  layers  of  tissue.  A 
glycerin  dressing  by  its  hygroscopic  power 
will  allow  of  speedy  absorption. 

Examine  the  umbilicus  and  the  inguinal 
and  femoral  canals  in  all  cases  of  obscure 
intestinal  obstruction.  Small  strangulated 
femoral  hemiae  often  simulate  very  closely 
the  feel  and  appearance  of  a  gland,  and  in 
such  cases  one  may  be  easily  misled. 

In  ligating  the  omentum,  it  is  a  good  rule 
never  to  place  a  ligature  around  a  piece 
larger  than  the  width  of  a  finger. 

Bloody  stools  after  herniotomy  in  which 
omentum  is  amputated  are  usually  due  to 
thrombosis  extending  to  the  colon. 


66 


RECTUn. 


Hemorrhage  from  the  bowel  in  children  is 
not  infrequently  caused  by  a  polypus  in  the 
rectum. 

Prolapse  ani  is  a  frequent  accompaniment 
of  bladder  stone  in  children. 

Prolapse  of  the  rectum  in  children  usually 
yields  to  treatment  by  strapping  the  nates 
together  with  adhesive  plaster,  if  carried  out 
intelligently  and  persistently,  for  several 
weeks  or  months.  The  child  should  be 
obliged  to  defecate  in  the  recumbent  posture 
and  while  the  strap  is  on.  After  defeca- 
tion the  strap  is  removed,  the  parts  cleansed 
and  a  fresh  strap  applied,  all  while  the 
child  is  recumbent. 

A  mass  protruding  from  the  rectum  of  an 
infant  or  child  may  be  an  intussusception  and 
not  a  mere  prolapse. 

Don't  fail  to  make  a  digital  rectal  exami- 
nation in  cases  of  appendicitis  and  in  all  ail- 
ments when  the  diagnosis  is  obscure.  Nor 
should  it  ever  be  omitted  before  an  opera- 
tion upon  anal  disorders.  It  may  save  the 
embarrassment  of  a  subsequent  discovery  that 


67 


RECTUn. 


a  patient's  hemorrhoids,  for  example,  were 
but  an  expression  of  a  carcinoma  higher  up 
in  the  rectum. 

A  radical  operation  for  hemorrhoids 
should  not  be  undertaken  until  the  etiology 
of  the  piles  has  been  determined.  Some- 
times the  cause  is  an  obstruction  in  the  por- 
tal circulation  due  to  hepatic  disease.  Per 
contra,  abscess  of  the  liver  may  be  due  to  in- 
fection from  a  hemorrhoid  operation  per- 
formed even  some  months  before. 

In  case  of  sudden  pulmonary  infarct,  a 
patient  should  always  be  examined  for  hem- 
orrhoids. A  thrombosis  of  one  of  the  veins 
of  the  prostatic  plexus  may  also  be  the  cause. 

Bleeding  from  capillary  hemorrhoids  high 
in  the  rectum  usually  yields  to  injections  of 
cold  water,  or  a  cold  solution  of  tannic  acid. 
In  these  cases,  however,  it  is  important  to 
exclude  the  presence  of  an  ulcer  further  up. 

If  a  thrombosing  pile  is  opened  before 
the  clotting  is  complete,  it  is  very  apt  to  fill 
up  again  and  may  even  become  edematous 
and  inflamed. 


68 


KCCTUn 


When  removing  hemorrhoids  much  atter- 
pain  and  edema  may  be  obviated  by  making 
radiating  nicks  in  the  skin  margin  of  the 
anus. 

To  relieve  the  edema  following  a  hemor- 
rhoid operation,  apply  a  glycerin  dressing 
covered  with  rubber  protective. 

After  an  operation  for  hemorrhoids  it  is 
desirable  to  insert  into  the  rectum  a  tampon 
canula,  made  by  smearing  with  vaselin  gauze 
layers  wrapped  about  a  piece  of  rubber  tub- 
ing, about  three  inches  long  and  transfixed 
at  its  distal  extremity  with  a  large  safety  pin. 
The  tampon  canula  prevents  oozing  by  its 
gentle  pressure,  allows  any  considerable  hem- 
orrhage to  show  itself  externally,  makes  the 
escape  of  flatus  painless  and  the  introduction 
of  an  oil  enema  easy. 

A  moderate  prolapse  of  the  rectum  with 
hemorrhoids  may  possibly  be  relieved  by  the 
treatment  of  the  hemorrhoids  with  clamp  and 
cautery. 

Blood  lost  at  stool  in  the  form  of  a  jet 
is  practically  always  from  a  hemorrhoid. 


69 


KECTUM. 


Although  profound  anesthesia  is  required 
to  abolish  the  anal  reflex,  chloroform  or  ether 
is  not  always  needed  in  order  to  divulse  the 
sphincter  ani.  This  may  be  accomplished 
painlessly,  and  often  with  fair  satisfaction, 
under  ethyl  chlorid  or  nitrous  oxid  narcosis, 
especially  if  an  opium  suppository  is  intro- 
duced a  half-hour  beforehand,  and  a  pledget 
of  cotton  wet  in  cocain  solution  is  applied 
just  before  the  operation. 


After  operations  upon  the  rectum,  espe- 
cially after  those  involving  divulsion  of  the 
sphincter  ani,  voluntary  urination  is  apt  to  be 
inhibited  for  a  day  or  more.  This  is  espe- 
cially the  case  when  stretching  is  done  in  a 
sagittal  direction,  i  e.,  towards  the  urethra 
and  the  coccyx.  It  may  save  catheterization, 
therefore,  if  the  stretching  is  done  only  later- 
ally, i.  e.,  towards  the  tubera  ischii. 


The  only  evidence  of  an  acute  intussuscep- 
tion may  be  the  passage  of  a  small  amount 
of  blood  per  rectum.  One  should  always 
make  a  thorough  rectal  examination  for  an 
intussusception  even  high  up  in  the  small  in- 
testine may  sometimes  be  felt  per  rectum. 


70 


RECTUM. 


Stretching  the  anal  sphincter  alone  will  in 
many  instances  relieve  an  intense  pruritus  or 
a  small  prolapse  of  the  anal  mucus  mem- 
brane. 


The  insertion  through  the  sphincters  at 
night,  for  a  few  minutes  at  a  time,  of  a  coni- 
cal dilator  (e.  g.,  of  hard  rubber),  of  gradu- 
ally increasing  size,  is  often  a  valuable  ad- 
junct in  the  treatment  of  pruritus  ani. 


When  pruritus  ani  is  caused  by  a  local 
eczema  it  is  well  to  remember  that  the  latter 
may  be  seborrheal  in  origin.  In  such  cases 
other  areas  of  the  disease,  as  on  the  chest 
and,  especially,  the  scalp,  should  be  sought 
for;  they  will  require  attention  also,  in  order 
to  effect  a  cure. 

What  a  patient  describes  as  a  diarrhea 
may  be,  instead,  a  fecal  stained  mucoid  dis- 
charge due  to  the  irritation  from  impacted 
feces  in  the  rectum. 

A  complaint  of  excessive  moisture  about 
the  anal  groove  should  not  be  dismissed  with- 
out a  careful  examination  for  a  fistula. 


RECTUn. 


Severe  burning  pain  in  the  anus  coming  on 
during,  or  just  after  defecation,  and  lasting 
for  but  a  short  time,  almost  always  points 
to  the  presence  of  a  fissure  or  ulcer.  It  may 
be  very  small  and  thus  elude  all  but  a  most 
thorough  search. 


OENITO- 

UWNAKy 

TRACT, 

Kidney  and 
Ureter. 


It  is  not  sufficiently  established  that  the 
character  of  the  crystals  found  in  the  urine 
indicates  the  presence  or  identity  of  lithiasis 
in  the  urinary  tract.  When  cystin  crystals 
are  constantly  found  in  the  sediment,  how- 
ever, if  symptoms  of  lithiasis  are  present,  the 
stone  is  probably  made  up  of  cystin. 


An  approximate  determination  of  the  or- 
igin of  a  hematuria  may  be  obtained  by  not- 
ing the  following  points:  If  pure  blood  is 
followed  by  clear  urine,  the  origin  is  in  the 
urethra;  if  the  patient  first  passes  urine,  then 
blood,  the  source  of  bleeding  is  probably  in 
the  bladder;  if  urine  evenly  mixed  with 
blood  is  voided,  the  kidney  is  probably  re- 
sponsible for  the  hemorrhage;  if  long,  fine 
clots  resembling  worms  are  passed,  these, 
usually,  are  from  the  ureter. 


72 


QENITO-URINAtty  TRACT, 


A  point  worth  remembering  in  the  diag- 
nosis of  nephrolithiasis  is  that  red  blood  cells 
are  almost  always  found  in  the  centrifuga- 
lized  sediment  of  the  urine  even  in  the  inter- 
val between  attacks  of  colic. 

In  a  very  acid  urine  red  blood  cells  may  be 
disintegrated  and  appear  under  the  micro- 
scope as  an  amorphous  material.  When  it 
is  important  to  determine  the  presence  or  ab- 
sence of  blood  in  the  urine  it  is  sometimes 
necessary,  therefore,  to  resort  to  a  chemical 
test,  e.  g.,  that  with  guaiac  resin. 


A  radiographic  shadow  simulating  that  of 
a  urinary  calculus  may  be  produced  by  an 
atheromatous  plaque,  as,  for  example,  in  the 
internal  iliac  artery,  a  phlebolith,  a  calcareous 
gland,  or  a  calcified  enterolith  in  the  appen- 
dix. 


When  skiagraphing  for  suspected  renal  cal- 
culus the  entire  urinary  tract  should  be  ex- 
posed, I.  e.,  the  kidney  regions,  ureters  and 
bladder.  Not  infrequently  a  stone  supposed 
to  be  in  the  kidney  may  be  lodged  in  the 
lower  end  of  the  ureter,  within  reach  from 
the  bladder. 


73 


OENITO-URIINAKy  TRACT. 


By  a  careful  study  of  an  x-ray  plate  it 
can  usually  be  determined  with  fair  accuracy 
whether  a  renal  calculus  is  in  the  pelvis  of 
the  kidney  or  in  the  parenchyma,  at  the 
upper  pole  or  the  lower  pole. 

In  cases  of  renal  colic  do  not  make  too 
positive  a  pre-operative  diagnosis  of  calculus, 
no  matter  how  typical  the  symptoms  may  be. 
It  has  happened  very  often  at  the  time  of 
operation  that  no  stone  is  found.  Fortu- 
nately, these  cases  are  nearly  always  cured 
by  the  exploratory  nephrotomy. 

Attacks  of  abdominal  pain  associated  only 
with  intestinal  symptoms,  may  nevertheless 
be  due  to  a  renal  or  ureteral  calculus,  even 
though,  in  addition,  a  tender  area  may  be 
palpated  at  a  point  more  or  less  remote  from 
the  kidney  regions. 

The  perinephric  space  is  a  frequent  site  of 
metastatic  inflammation  after  furunculosis  or 
other  septic  infection. 

After  nephrotomy,  hemorrhage  may  usually 
be  stopped  by  inserting  deep  mattress  sutures 
into  the  kidney  substance  followed  by  super- 
ficial sutures  of  the  same  kind. 


74 


OCNITO-URINARy  TRACT. 


If  possible,  always  tie  each  component  of 
a  kidney  pedicle  separately,  not  en  masse. 

If  a  stump  ligature,  e.  g.,  of  the  renal  pe- 
dicle, is  slow  to  come  away,  the  process  may 
be  hastened  by  fastening  it  taut  to  a  piece  of 
rubber  tubing  stretched  across  the  wound. 

If  pus  persists  in  the  urine  after  the  extir- 
pation of  a  kidney  for  suppurative  disease, 
it  often  means  that  the  ureter  is  involved  and 
will   require  subsequent  extirpation. 

When  operating  upon  the  ureter  for  cal- 
culus or  stricture,  avoid  undue  manipulation; 
it  is  important  to  detach  the  ureter  from  its 
bed  as  little  as  possible. 

Hypernephroma  is  distinguished  from  the 
other  malignant  tumors  of  the  kidney  by  the 
very  early  appearance  of  hematuria. 

Pyuria  without  symptoms  is  suspicious  of 
an  early  tuberculosis  of  the  urinary  tract. 

The  examination  for  tubercle  bacilli  in  the 
urine  by  the  ordinary  method  of  staining,  is 
not  decisive  by  any  means,  even  if  the  blad- 
der   has    been    catheterized    and   differential 


75 


OENITO-URINARy  TRACT. 


stains  for  smegma  bacilli  have  been  em- 
ployed. Numerous  examinations  with  the 
aid  of  these  procedures  must  be  made,  and 
even  then  the  diagnosis  is  only  a  presumptive 
one.  The  only  sure  test  is  by  injecting  a 
large  quantity  of  the  sediment  into  a  guinea- 
pig. 

5lAd<icr.  Most  cases  of  sudden,  unexpected  hemor- 

rhage from  the  urethra  are  due  to  malignant 
disease,  but  it  is  well  to  remember  that  there 
are  cases  of  genito-urinary  tuberculosis  in 
which  such  a  hemorrhage  is  the  first  symptom. 

Hemorrhage  from  the  bladder  may  yield 
to  irrigations  with  ice-cold  water  and  with 
1-10,000  adrenalin  solution,  successively. 

Never  attempt  to  pack  a  bladder  for 
hemorrhage  without  the  aid  of  guy  sutures; 
with  them  one  can  make  absolutely  sure  that 
the  gauze  goes  into  the  bladder,  and  not  on 
top  of  it,  pushing  the  organ  away  from  the 
space  of  Retzius. 

Post-operative  hemorrhage  from  the  base 
of  the  bladder  that  proves  inaccessible  to  lig- 
atures, and  uncontrollable  by  packings,  may 
be     checked     by     the     following     method: 

76 


GENITOURINARY  TRACT. 


Through  several  thickness  of  gauze,  cut  in 
squares,  pass  a  double  strand  of  heavy  silk 
or  of  twine  fastened  on  a  stout  needle.  With 
the  patient  in  Trendelenburg's  position  and 
the  bladder  widely  opened,  thrust  the  needle 
from  within  directly  through  the  perineum, 
and  bring  the  gauze  firmly  against  the  bleed- 
ing surface  by  pulling  upon  the  threads,  which 
are  then  to  be  fastened  to  an  outside  dressing. 

It  is  a  peculiar  fact  that  many  of  the  cases 
of  tumor  of  the  bladder  occur  among  work- 
ers in  anilin  dyes. 

It  should  be  borne  in  mind  that  stone  in 
the  bladder  may  be  the  primary  cause  in 
children  of  enuresis,  masturbation  or  prolap- 
sus recti. 

What  feels  at  the  other  end  of  the  searcher 
like  a  stone  in  the  bladder,  may  be  a  fold 
of  mucous  membrane  encrusted  with  urinary 
deposit. 

In  cases  of  suspected  rupture  of  the  blad- 
der, catheterization  is  not  a/lpaps  a  sure  test. 
The  rent  may  be  so  large  that  the  catheter 
draws  away  urine  that  has  already  flowed 
into  the  peritoneal  cavity. 


77 


OENITO-URINARY  TRACT 


To  prevent  a  suprapubic  or  other  drain- 
age tube  from  becoming  displaced  fit  another 
tube  over  it  like  a  collar;  this  outer  tube  is 
split  through  half  its  length  and  the  two  por- 
tions are  spread  out  over  the  skin  and  fast- 
ened down  with  adhesive  plaster. 

If  the  bladder  does  not  drain  after  a  supra- 
pubic cystostomy,  in  all  probability  the  ca- 
theter or  drainage  tube  has  become  displaced 
into  the  space  of  Retzius. 

Involuntary  urination  very  often  means  a 
distended  bladder,  and  in  old  men  it  should 
at  once  indicate  an  examination  into  the  con- 
dition of  the  prostate.  Vomiting,  too,  is 
often  caused  by  distention  of  the  bladder. 

An  acutely  distended  bladder  should  not 
be  completely  emptied  in  one  sitting.  Its 
rapid  collapse  may  produce  hemorrhagic  cys- 
titis. 

Before  employing  a  rubber  catheter  test 
its  resiliency.  If  it  is  brittle  or  cracked,  dis- 
card it.  Not  infrequently  a  rotten  catheter 
breaks  off  in  the  bladder  while,  of  course, 
a  rough  catheter  or  sound  may  play  havoc 
in  the  urethra. 


78 


OCINITO-URINARy  TRACT. 


One  should  watch  carefully  for  overdis- 
tention  of  the  bladder  in  all  cases  of  lesions 
of  the  spinal  cord.  In  children  the  bladder 
has  been  known  to  distend  sufficiently  to  hold 
20-40  ounces. 

Before  deciding  on  the  necessity  for  a 
laparotomy  for  some  vague  abdominal  con- 
dition, where  distention  is  present,  empty  the 
bladder.  In  many  cases  the  acute  abdominal 
distress  will  disappear. 

Unconscious  patients  should  be  catheter- 
ized  at  regular  intervals  of  about  eight  hours. 

Rectal  examination  sometimes  aids  in  de-  Prostate. 
termining  the  variety  of  obstruction  in  pros- 
tatic hypertrophy.  If  the  prostate  is  com- 
paratively small,  the  obstruction  is  probably 
due  to  the  middle  lobe;  if  large,  to  the  later- 
al lobes. 

A  Mercier  catheter  is  the  first  kind  that 
ought  to  be  employed  in  attempting  to  over- 
come retention  caused  by  an  enlarged  pros- 
tate. Often  it  will  have  to  be  resorted  to 
in  the  end;  and,  therefore,  it  will  save  much 
unsuccessful  manipulation  to  use  it  at  once. 
Occasionally,  a  metal  catheter  will  pass  when 
even  a  Mercier  fails. 


79 


OEISITO-URIINARY  TRACT. 


Never  open  a  prostatic  abscess  per  rectum, 
no  matter  how  much  it  bulges;  always  oper- 
ate through  the  perineum. 

It  is  a  wise  rule  to  submit  all  removed 
hypertrophied  prostates  to  thorough  examina- 
tion by  a  pathologist.  Carcinomatous  de- 
generation may  be  found  in  some  spot. 

Carcinoma  of  the  prostate  often  does  not 
recur  for  some  time;  meanwhile  the  patient 
may  look  surprisingly  well.  This  should  not 
beguile  the  surgeon  into  a  too  hopeful  prog- 
nosis. 

Pcni»  and  Force  is  never  helpful  in  overcoming  the 

Urethra.  resistance  of  a  stricture  to  instrumental  pas- 
sage; it  is  bound  to  do  harm.  A  combina- 
tion of  patience  and  hot  applications,  with 
a  strong  admixture  of  gentleness  and  judg- 
ment, will  effect  the  desired  result  in  most 
cases. 

A  swelling  or  redness  behind  the  scrotum, 
in  cases  of  urethral  stricture  or  developing 
after  urethral  instrumentation,  usually  means 
urinary  extravasation,  which  requires  prompt 
and  active  treatment. 


80 


OENITO-URINARy  TRACT. 


One  death  from  urethral  sepsis  is  enough 
to  impress  upon  one  the  importance  of  the 
teaching  that  perineal  drainage  should  al- 
ways be  employed  after  internal  urethrotomy 
three  or  more  inches  from  the  meatus. 

When  performing  external  urethrotomy 
without  a  guide  it  is  often  possible  to  trace 
the  continuation  of  the  urethra  proximal  to 
the  opening,  by  means  of  a  filiform  bougie, 
even  when  all  devices  failed  to  secure  the 
introduction  of  a  filiform  before  the  opera- 
tion. If  a  filiform  cannot  be  thus  passed 
through  the  urethral  wound,  suprapubic  pres- 
sure on  the  bladder  may  demonstrate  the  lo- 
cation of  the  urethral  orifice  by  the  escape  of 
a  drop  of  urine  or  by  bulging  of  the  mem- 
branous urethra. 

Avoid  the  temptation  to  employ  a  con- 
strictor upon  the  penis  when  performing  cir- 
cumcision, etc.  It  may  cause  sloughing,  or 
actual  gangrene. 

After  circumcision  it  is  important  to  pre- 
vent adhesion  of  the  reflected  mucous  fold 
of  the  prepuce  to  the  corona  glandis,  by  the 
daily  passage  of  a  probe  about  the  corona, 
and  by  the  use  of  vaselin. 


8r 


OEINiTOURINARY  TRACT 


Absorbent  cotton,  so  commonly  used  to 
catch  the  discharge  of  gonorrhea,  is  very 
inelegant.  It  sticks  to  the  glans,  allows  the 
meatus  to  glue  together,  and  is  difficult  to 
remove  without  soiling  the  fingers.  The  fol- 
lowing is  the  cleanliest  and  most  surgical 
dressing:  In  a  six  inch  square  of  surgical 
gauze,  of  about  four  thicknesses,  cut  a  slit 
in  the  middle  just  large  enough  to  be  passed 
over  the  glans  and  to  be  held  behind  the 
corona.  Then  simply  draw  the  foreskin  for- 
ward. Indeed,  such  a  dressing  will  hold 
even  if  the  patient  has  been  circumcised,  if 
the  slit  in  the  gauze  is  not  too  large.  With 
such  a  simple  dressing,  there  is  no  retention 
of  the  pus,  no  irritation  from  contact  with 
the  secretions,  the  organ  is  readily  inspected 
and  the  gauze  is  easily  drawn  off  by  a  little 
pull  at  one  of  its  clean  corners. 


Non-specific  urethral  discharges  in  young 
boys  may  be  due  to  foreign  bodies  introduced 
while  masturbating. 


Examine  the  inguinal  regions  for  hernia  in 
all  cases  of  very  tight  prepuce  causing  diffi- 
culty in  micturition. 


82 


OEINITOURINAUy  TRACT, 


If  difficulty  is  experienced  in  reducing  a 
paraphimosis  because  of  swelling,  before  di- 
viding the  constriction  apply  a  rubber  band- 
age around  the  parts  for  a  few  minutes;  this 
may  relieve  the  swelling  to  such  an  extent 
that  the  paraphimosis  can  be  easily  reduced. 

A  comforting  support  for  the  testicles, 
when  a  patient  is  confined  to  bed  with  or- 
chitis, is  easily  furnished  by  a  well-padded 
cigar  box  cover,  grooved  to  fit  under  the 
scrotum,  and  laid  across  the  thighs.  Ad- 
hesive plaster  may  be  used  in  the  same  man- 
ner. 

In  hydrocele  the  base  of  the  tumor  is  be- 
low, in  spermatocele  it  is  usually  above.  A 
milky  fluid  obtained  by  aspiration  usually 
speaks  for  spermatocele. 

If  a  cystic  swelling  in  the  scrotum  is 
opaque  when  examined  by  the  well-known 
transillumination  test,  especially  if  a  history 
of  traumatism  is  elicited,  it  may  still  be  a 
hydrocele.  Admixture  of  blood  in  the  hy- 
drocele destroys  its  translucency. 

The  early  reappearance  of  fluid  after  tap- 
ping a  hydrocele  does  not  necessarily  mean 

83 


Scrotum 

and 

Tcaticlc. 


OENITO-URIINARY  TKACT. 


that  the  operation  has  been  a  failure.  It 
may  be  but  an  inflammatory  reaction,  sub- 
siding spontaneously  or  under  the  application 
of  unguentum  iodi. 

If  a  male  patient  with  supposed  strangu- 
lated hernia  complains  of  pain  running  down 
the  inner  aspect  of  the  thigh  it  is  well  to 
think  of  torsion  of  the  testicle. 

A  swelling  in  the  inguinal  region,  painful 
to  the  touch  is,  of  course,  often  an  inguinal 
adenitis  (e.g.,  following  gonorrhea).  But 
an  inflamed  undescended  testicle  should  be 
kept  in  mind. 

Accumulated  experience  shows  that  cas- 
tration alone  will  not  cure  the  great  ma- 
jority of  cases  of  tuberculosis  testis.  In 
many,  if  not  most,  cases  the  vas  deferens, 
seminal  vesicle  or  prostate  is  involved,  and 
it  will  be  necessary  to  remove  one  or  more 
of  these  structures  in  order  to  cure.  More- 
over the  other  testicle  frequently  becomes 
tuberculous.      Open-air  therapy  is  helpful. 

Orchitis  after  an  operation  for  hernia  is 
best  relieved  by  a  wet  or  glycerin  dressing 
with  elevation  of  the  scrotum. 


84 


QENITO-URINARY  TRACT. 


Syphilitic  interstitial  orchitis  resembles 
closely  in  appearance  new  growth  of  the 
testicle.  Unless  the  diagnosis  of  neoplasm 
is  beyond  all  doubt,  an  active  course  of 
specific  treatment  should  be  tried  before  re- 
moving the  testicle. 


In  excising  a  varicocele  under  local  anes- 
thesia, tie  the  upper  ligature  first;  the  pain 
of  tying  the  lower  ligature  will  then  be  abol- 
ished. 


After  the  open  operation  for  varicocele 
the  scrotum  may  be  shortened  by  simply  sew- 
ing the  wound  together  transversely  instead 
of  longitudinally. 


The  presence  of  varicocele,  especially  if 
unilateral,  should  suggest  an  examination  of 
the  abdomen  and  pelvis  for  a  possible  growth 
pressing  on  the  spermatic  veins. 


It  is  a   good  rule  to  always  inspect  the  PEnALE 

labia  before  making  a  vaginal  examination.  riPNpDAXlVF 

Many  pathological  conditions  in  these  parts  /-kr>p  aiwc 

may  otherwise  pass  unsuspected.  VJkVJAPIo. 

85 


reriALE  generative  oroais5. 


Don't  be  tempted  to  exclude  gonorrhea 
because  you  see  no  bacterial  or  other  evi- 
dence of  vaginal  or  urethral  infection.  In 
women  the  presence  of  gonorrhea  may  not 
make  itself  known  for  six  weeks  or  more, 
and  salpingitis  may  be  the  first  evidence. 

When  the  openings  of  the  Bartholinian 
glands  appear  as  two  sharply  defined  red 
spots,  an  antedating  inflammation  may  be 
diagnosed  with  certainty,  and  in  a  great  ma- 
jority of  instances  a  latent  gonorrhea  is  pres- 
ent. 

Simple  incision  is  not  sufficient  in  the  treat- 
ment of  Bartholinian  abscesses.  They  should 
be  cauterized  daily  with  iodin,  and  if  they 
recur,  excised. 

Furunculosis  vulvae,  even  when  it  persists 
in  spite  of  all  other  treatment,  will  often 
yield  to  daily  scrubbing  with  green  soap  and 
the  application  of  a  dressing  of  sublimate 
solution. 

When  cleansing  the  vagina  and  vulva  in 
preparation  for  an  operation,  a  soft  cotton 
mop  should  be  used  for  the  vestibule;  a 
stiff  brush  is  too  apt  to  bruise  or  lacerate 
the  urethra  and  cause  dysuria  for  some  days 
thereafter. 

86 


PEMALE  OENEKATIVE  OR0AN5. 


The  use  of  any  considerable  quantity  of 
iodoformized  gauze  in  the  vagina  involves  the 
risk  of  a  severe  dermatitis  of  the  vulva. 


In  the  case  of  a  vesico-vaginal  fistula,  the 
vaginal  opening  can  readily  be  discovered  by 
the  injection  of  methylene  blue  into  the  blad- 
der and  noting  its  escape  through  the  vagina. 
If,  however,  the  opening  communicates  with 
the  ureter,  the  blue  colored  fluid  cannot  be 
seen.  In  such  a  case,  a  catheter  at  times 
can  be  passed  directly  from  the  vaginal  open- 
ing into  the  ureter. 

One  should  always  examine  the  anterior 
vaginal  wall  carefully  when  there  is  any  ure- 
thral discharge  for  it  may  be  due  to  a  peri- 
urethral abscess  communicating  with  an  in- 
fected vaginal  cyst. 

Before  performing  curettage  always  make 
a  final  bimanual  examination  of  the  uterus 
in  narcosis.  The  finding  may  determine  some 
other  form  of  treatment.  Again,  after  curet- 
tage, before  allowing  the  patient  to  get  out 
of  bed,  carefully  examine  the  pelvis  for  signs 
of  a  possible  exudate. 


87 


rEMALE  GENERATIVE  OK0AIN5. 


As  a  final  cleansing  step  after  curettage 
of  the  uterus  it  is  well  to  introduce,  and  at 
once  withdraw,  a  packing  of  gauze.  This 
brings  out  with  it  fragments  of  tissue  not 
washed  out  by  the  irrigation. 

Sudden  collapse  after  a  curettage  for  sup- 
posed abortion  may  mean  the  rupture  of  an 
unsuspected  ectopic  gestation  sac. 

A  rise  of  temperature  after  a  curettage  may 
be  due  to  a  piece  of  gauze  having  been  left 
in  the  uterus  too  long. 

A  high  temperature  just  after  or  during 
an  abortion  is  evidence  of  intrauterine  manip- 
ulation, especially  if  the  discharge  from  the 
uterus  is  fetid. 

Bleeding  after  coitus  is  sometimes  the  earli- 
est sign  of  cancer  of  the  cervix. 

Persistent  bleeding  or  irregular  prolonged 
menstruation  is  very  suggestive  of  uterine 
fibroids. 

Uterine  fibroids  may  be  differentiated  from 
disease    of   the    tubes   or    ovaries   by   noting 


88 


reriALE  generative  organs. 


whether  or  not  the  cervix  moves  in  the  oppo- 
site direction  when  the  tumor  is  pushed  from 
side  to  side. 

An  obstinate  constipation  may  be  due  to 
an  extreme  retroflexion  of  the  uterus,  the  or- 
gan lying  in  the  hollow  of  the  sacrum. 

Carcinoma  of  the  cervix  may  remain  hid- 
den in  the  lumen  of  the  cervical  canal,  which 
is  then  eroded  and  forms  an  irregular  ellipti- 
cal cavity.  While  the  external  os  is  closed 
suspicion  of  the  serious  condition  present  will 
be  attracted  by  the  foul  or  bloody  discharge. 

No  operation  for  sterility  in  the  female 
should  be  performed  without  first  excluding 
sterility  on  the  husband's  part. 

In  case  of  hematocolpos  and  hematometra 
it  is  essential  to  precede  all  interference  by  a 
careful  rectal  examination  in  order  to  de- 
termine whether  the  tubes  are  distended  or 
not.  If  hematosalpinx  exists  a  laparotomy 
and  salpingectomy  must  precede  the  vaginal 
operation,  otherwise  a  severe  peritonitis  may 
be  set  up  by  a  reflex  discharge  of  infective 
secretion  from  the  tubes. 


89 


TEMALE  GENERATIVE  OR0AN5. 


Mobile  retroflexions  that  resist  manual  re- 
position are  often  easily  and  painlessly  cor- 
rected by  placing  the  patient  in  the  knee-chest 
position  and  then  depressing  the  perineum. 
The  sudden  inrush  of  air  balloons  out  the 
vagina   and   this   effects   the   desired   results. 

In  the  early  months  of  pregnancy  exami- 
nations should  be  made  to  determine  that 
there  is  no  retroversion,  or  to  treat  it  if  it 
exists.  A  retroverted  gravid  uterus  impacted 
in  the  curve  of  the  sacrum  always  aborts. 

Ascites  in  the  presence  of  a  mass  in  the 
pelvis  usually,  but  not  necessarily,  means 
malignancy. 

Avoid  introducing  a  uterine  sound  in  ex- 
aminations vv^hen  pelvic  inflammation  is  sus- 
pected.    It  may  set  up  a  parametritis. 

Impaction  of  feces  in  the  sigmoid  and  rec- 
tum, with  absorption  symptoms,  may  simu- 
late pelvic  peritonitis. 

In  pulling  on  the  round  ligaments  in  the 
Alexander  operation,  use  the  fingers  rather 
than  instruments;  a  surer  hold  is  given,  one 


90 


PEfiALE  OEINERATIVE  OROA^5. 


can  gauge  the  proper  force  to  employ  more 
readily,  and  there  is  less  likelihood  of  the 
ligaments  tearing. 

The  sudden  acute  onset  of  abdominal  pain 
with  tenderness  over  the  appendix  region  but 
with  rigidity  of  the  right  rectus  low  down,  is 
very  suggestive  of  acute  salpingitis.  The 
diagnosis  is  further  confirmed  if  there  is  high 
temperature  and  extremely  high  leucocyte 
count  (20,000-40,000;  polynuclears,  80- 
90%),  even  though  vaginal  examination  be 
negative. 

Twisting  of  the  pedicle  of  an  ovarian  cyst 
often  produces  all  the  signs  and  symptoms  of 
acute  or  recurrent  appendicitis. 

An  ovarian  cyst  with  a  long  pedicle  may 
be  found  in  any  part  of  the  abdominal  cav- 
ity. It  rarely  gives  pain  unless  the  pedicle 
becomes  twisted.  In  such  a  case,  a  differ- 
ential diagnosis  between  it  and  a  hydrone- 
phrosis is  very  difficult.  One  may  suspect 
the  true  condition  by  the  mobility  of  the 
tumor. 

The  presence  of  a  Head  zone  starting  in 
the  inguinal  region  and  extending  down  the 


91 


reriALE  GENERATIVE  OROAN5. 


thigh  in  the  form  of  a  kite  (tail  downward) 
should  make  one  examine  the  pelvic  organs 
thoroughly,  for  the  lesion  very  probably  is  in 
the  adnexa. 

Do  not  exclude  the  diagnosis  of  extra- 
uterine pregnancy  merely  because  vaginal  ex- 
amination reveals  no  mass  in  the  pelvis. 

The  palpation  of  a  pulsating  vessel  in  the 
vaginal  fornix  of  a  woman  who  has  skipped 
a  menstrual  period,  will  often  give  the  clue  to 
a  possible  ectopic  gestation. 

In  rupture  of  an  ectopic  gestation  sac  and 
hemorrhage,  the  patient  may  refer  the  pain 
chiefly  to  the  region  of  the  right  hypochon- 
drium,  and  this  may  deceive  the  physician  into 
the  belief  that  he  is  dealing  with  a  case  of 
cholelithiasis.  A  careful  history,  vaginal  ex- 
amination, and  the  evidences  of  internal  hem- 
orrhage will  differentiate  the  conditions. 

An  abscess  of  the  right  ovary  may  give 
the  same  signs  and  symptoms  as  acute  ful- 
minating appendicitis.  If  an  incision  for  ap- 
pendicectomy  is  made,  it  should  be  of  suffi- 
cient length  and  low  enough  down  to  allow 
of  careful  examination  of  the  right  adnexa. 


92 


reriALE  generative  organs. 


A  large  tumor  supposedly  a  growth  of  the 
ovary  may  be  a  retroperitoneal  mass,  usually 
a  sarcoma,  having  no  connection  with  the  sex- 
ual organs. 

In  all  cases  of  lumbago,  especially  of  the  BACK, 

chronic  variety,  examine  the  sacro-iliac  joints 
for  tenderness.  Such  cases  may  sometimes 
be  almost  instantaneously  relieved  by  apply- 
ing broad  strips  of  plaster  from  beyond  one 
superior  iliac  spine  to  the  other,  across  the 
back.  The  straps  must  be  applied  tightly 
and  with  the  feet  close  together. 

A  skin-lined  sinus  opening  between  the 
coccyx  and  the  anus,  when  not  very  short, 
usually  leads  to  a  dermoid  cyst  situated  close 
to  the  coccyx.  Frequently  loose  hairs  from 
the  dermoid  may  be  found  in  the  sinus. 

A  large  abscess  in  the  ischio-rectal  region 
may  communicate  with  an  infected  dermoid 
cyst  at  the  base  of  the  spine. 

Congenital  paralysis  of  the  lower  limbs 
may  arise  from  an  internal  sacral  or  coccy- 
geal spina  bifida.      In  such  cases  rectal  ex- 


93 


BACK. 


TIES. 


amination  reveals  the  trouble  and  an  opera- 
tion may  afford  marked  improvement  or  even 
a  brilliant  cure. 

In  a  case  of  possible  fracture  or  disloca- 
tion of  the  spine,  give  instructions  that  the 
patient  be  kept  absolutely  quiet  in  order  to 
prevent  an  aggravation  of  the  deformity. 

A  tumor  on  either  side  of  the  vertebral 
column  with  a  slight  bulging  in  this  region 
and  scoliosis,  is  often  a  perinephric  abscess. 
But  if  cord  symptoms  are  present,  a  sarco- 
matous growth  of  the  vertebrae  should  be 
kept  in  mind. 

Do  not  consider  too  lightly  a  history  of 
"growing  pains"  in  the  extremities  in  chil- 
dren. These  symptoms  may  be  due  to  a 
grave  osteomyelitis. 

Do  not  be  in  a  hurry  to  perform  primary 
amputations  after  severe  traumata  of  the  ex- 
tremities. First,  combat  the  shock  and  pre- 
vent hemorrhage.  Keep  the  wound  as  clean 
as  possible;  and  only  when  the  patient  has 
quite  recovered  from  his  shock  (at  the  end 
of  a  few  days  or  more),  perform  the  ampu- 
tation. 


94 


EATttEniTlE5. 


Pulsation  in  the  course  of  an  artery  should 
not  lead  to  the  hasty  conclusion  that  one  is 
dealing  with  an  aneurism.  A  tumor  over- 
lying a  large  vessel,  and  also  a  vascular  sar- 
coma of  the  bone,  may  simulate  an  aneu- 
rism very  closely. 

Never  incise  a  swelling  in  the  course  of  a 
large  artery  without  first  making  sure  that  it 
is  not  an  aneurism. 

When  clamping  a  vein  in  continuity  se- 
cure the  proximal  end  first;  otherwise  it  will 
empty  and  may  become  lost  to  view. 

In  acute  (septic)  osteomyelitis  immediate 
operation  is  not  too  radical;  in  chronic  os- 
teomyelitis patient  waiting  is  often  not  too 
conservative — the  final  expulsion  of  a  seques- 
trum may  be  all  that  is  necessary  to  effect 
spontaneous  cure. 

In  acute,  no  less  than  in  chronic  osteomye- 
litis of  the  long  bones,  an  x-ray  picture  is  of 
immense  service  as  a  guide  in  the  operation. 
It  determines  the  exact  locaton,  extent  and 
even  character,  of  the  disease  focus,  and  thus 
it  saves  much  unnecessary  destruction  of  bone 
by  the  surgeon's  chisel. 


95 


EATREMITIES. 


When  performing  amputation,  arthrec- 
tomy,  osteotomy  or  similar  operation  it  is 
wiser  to  leave  the  constrictor  in  place  until 
the  dressing  is  partly,  or  entirely,  applied, 
than  to  remove  it  after  tying  the  large  ves- 
sels, in  an  effort  to  secure  the  small  ones. 
In  the  former  case  the  snugly  applied  dress- 
ing will  safely  prevent  hemorrhage;  in  the 
latter  case,  there  may  be  an  alarming  loss 
of  blood  from  the  numerous  small  vessels  in 
the  very  time  the  efforts  are  made  to  tie  them 
all. 

Do  not  amputate  an  extremity  for  sar- 
coma without  a  previous  careful  examina- 
tion of  the  lungs  and  mediastinum  for  me- 
tastasis. Such  symptoms  as  continued  cough, 
a  small  hemoptysis  or  beginning  dyspnea, 
should  be  regarded  as  highly  suggestive  of 
such  a  complication. 

After  major  amputations  an  elastic  con- 
strictor should  always  be  left  at  the  head  of 
the  bed,  so  that  the  nurse  can  immediately 
apply  it  in  case  of  secondary  hemorrhage. 

A  synovitis  that  persists  despite  careful 
treatment  should  arouse  suspicion  of  tuber- 
culosis. 


96 


EATRErilTlE5. 


A  chronic  synovitis  of  apparently  un- 
known origin  and  very  rebellious  to  treat- 
ment is  sometimes  due  to  a  small  focus  of 
osteomyelitis  just  beneath  the  cartilaginous 
surface. 

Suppurating  arthritides  do  not  always  re- 
quire exposure  of  the  joint  or  even  large  in- 
cisions, irrigation  and  drainage.  Such  treat- 
ment invites  mixed  infection  and  ankylosis. 
If  the  pus  be  very  thin — even  though  of  strep- 
tococcic origin — thorough  aspiration  (which 
may  need  to  be  repeated)  and  immobilization, 
may  effect  a  rapid  cure  with  perfect  func- 
tion. Purulent  arthritis  and  periarthritis  as 
it  occurs  in  small  children  as  a  complication 
of  one  of  the  exanthemata  (often  in  connec- 
tion with  trauma)  is  usually  quite  amenable 
to  conservative,  and  even  ambulant  treatment: 
aspiration,  or  irrigation  and  drainage,  and  im- 
mobilization. Judgment  is  needed,  of  course, 
to  determine  what  cases  are  amenable  to  this 
conservative  surgery,  and  at  what  point  in  the 
treatment  it  must  be  abandoned  in  favor  of 
more  extensive  intervention. 

A  chronic  cystic  swelling  in  the  neighbor- 
hood of  a  joint  is  in  the  majority  of  instances 
a  distended  bursa. 


97 


EATRErilTIE5, 


One  should  inquire  carefully  for  the  his- 
tory of  the  application  of  carbolic  acid  to  a 
wound,  especially  of  the  finger  or  toe,  when  a 
gangrene  with  a  distinct  line  of  demarkation 
has  developed. 


Resection  of  the  head  of  the  projecting 
phalanx  so  often  yields  an  entirely  satisfac- 
tory result  that  amputation  should  not  be  ad- 
vised for  hammer-toe  until  the  less  mutilat- 
ing operation  has  been  tried. 


An  acute  non-purulent  tenosynovitis  may 
ppcr  ^^    satisfactorily    treated    by    immobilization 

'        with  plaster  strips. 


The  superficial  location  of  the  ulnar  nerve 
must  be  borne  in  mind  when  incising  an  ab- 
scess about  the  inner  aspect  of  the  elbow. 

Persistent  pain  in  an  arm  may  be  due  to 
the  presence  of  a  "cervical  rib." 

Do  not  apply  an  elastic  ligature  about  the 
arm  without  first  interposing  a  towel.  This 
may  obviate  subsequent  paralysis. 


98 


EATUEniTIE5. 


A  sinus  leading  high  up  in  the  axilla  and 
discharging  a  moderately  clear  fluid  may 
communicate  with  the  shoulder  joint  or 
pleura. 

A  small,  hard,  tender  nodule  situated  over     Hand. 
the  thenar  or  hypothenar  eminences  may  be  a 
broken-down  dermoid  cyst. 

If  a  patient  presents  himself  with  a  pain- 
less cellulitis  of  the  finger  or  hand,  it  is  neces- 
sary to  make  a  careful  examination  for  the 
possible  presence  of  syringomyelia. 

The  injection  into  a  ganglion  of  the  wrist 
of  phenol-camphor,  two  to  ten  minims,  ac- 
cording to  the  size,  and  repeated  once  or 
twice  if  necessary,  will  cause  its  complete 
disappearance  in  most  cases.  No  attempt  at 
preliminary  aspiration  need  be  made. 

Before  anesthetizing  a  patient  to  operate 
upon  a  wound  (e.  g.,  of  the  wrist),  in  which 
tendons  are  severed,  attach  forceps  or  liga- 
ments to  any  tendon  ends  that  are  visible. 
While  struggling  during  primary  narcosis  the 
proximal  ends  of  cut  tendons  are  sometimes 
drawn  up,  and  the  above  device  will  obviate 


99 


EATREniTIE^. 


slitting  up  the  sheaths  to  secure  them. 
Squeezing  the  extremity  proximal  to  the 
wound  will  likewise  prevent  these  retractions. 

Never  divide  the  annular  ligament  of  the 
wrist.  The  hand  is  much  weaker  after  it  is 
divided  than  before. 

Frequently  referred  to  the  surgeon  because 
of  the  constant  pain  and  marked  tenderness, 
is  to  be  noted  a  group  of  cases  of  what  might 
be  termed  "occupation  wrist  pain."  They  dif- 
fer from  the  ordinary  case  of  "writer's 
cramp,"  "  piano-player's  cramp,"  etc.,  in 
that,  while  these  latter  frequently  have  pain 
in,  or  about,  the  wrist,  the  cases  here  re- 
ferred to  have  no  spasm,  the  pain  is  con- 
stant, and  it  is  not  of  a  neuralgic  character. 
Sometimes  it  radiates  along  the  thumb  (as  in 
mail-openers)  ;  sometimes  it  is  localized  to 
the  inner  border  of  the  lower  end  of  the  ulna, 
which  is  very  sensitive  to  pressure  (as  in 
shirt-ironers) .  The  fingers  are  free.  There 
may  be  pain  in  the  forearm  muscles  (flex- 
ors). 

For  a  single  tenorrhaphy  make  the  inci- 
sion quite  a  little  to  one  side  of  the  line  of 
the  tendon  and  perform  no  more  dissection 


TOO 


EATREniTIE5. 


than  is  necessary.     This  is  to  avoid  adhesions 
of  the  tendon  to  the  skin. 

If  a  tendon  has  been  divided  by  an  in- 
cised or  lacerated  wound  and  the  skin  has 
united  over  it,  it  is  better  to  wait  a  fortnight 
or  more  before  performing  tenorrhaphy. 
Otherwise  organisms  introduced  with  the 
traumatism  may  cause  suppuration  and 
sloughing  of  the  tendon,  not  only  defeating 
the  operation,  but  making  a  later  attempt  at 
approximation  difficult  or  impossible. 

When  exploring  for  a  needle  or  other  for- 
eign body  the  finger  tip  is  often  far  more  use- 
ful than  a  probe.  It  must  be  remembered, 
too,  that  strands  of  fascia  often  impart  to  a 
probe  "the  feel"  of  a  foreign  body.  Cut- 
ting and  picking  at  these  deceptive  strands 
of  tissue  soon  distort  the  field  of  operation 
and  destroy  important  relations.  It  is  ex- 
tremely desirable  to  conduct  a  systematic  and 
cleanly  dissection  when  seeking  a  foreign 
body. 

Stereoscopic  radiographs  best  demonstrate 
the  position  and  depth  of  a  needle  or  piece 
of  glass. 


lOI 


EATKEIilTIE^. 


The  best  drainage  should  be  afforded  for 
all  punctured  wounds  of  the  palm;  suppura- 
tions in  this  region  are  very  disagreeable  and 
are  followed  by  severe  consequences. 

The  surgeon  should  not  wait  for  redness 
before  making  a  diagnosis  of  palmar  abscess. 
Owing  to  the  density  of  the  fascial  structures 
this  sign  is  often  lacking  in  the  early  stages. 

In  dealing  with  infections  of  the  hand  bear 
in  mind  that  under  a  simple  bleb  may  lie  an 
extensive  phlegmon,  threatening,  or  actually 
involving,  a  tendon  or  bone  and  urgently 
needing  a  generous  but  wisely  placed  inci- 
sion; while  on  the  other  hand,  a  tendon  may 
be  thrust  from  its  protecting  sheath  into  the 
area  of  destruction  by  a  knife  sweep  more 
earnest  than  judicious.  A  crater-like  opening 
in  a  sodden  skin,  though  freely  discharging 
pus,  may  need  enlarging  to  protect  the  tissues 
underlying;  while  another  opening,  too  long 
continued  by  unnecessary  packing,  may  crip- 
ple a  joint  or  tendon  by  undue  cicatrization. 

In  the  treatment  of  hand  and  finger  in- 
fections, it  is  very  important  to  release  from 
bandaging  as  much  and  as  many  of  the  fin- 
gers as  possible,  and  as  soon  as  possible.   The 


I02 


EATREMITIE5, 


habit  of  bandaging  up  immovably  all  the 
fingers,  in  the  treatment  of  a  lesion  of  some 
of  them,  saves  the  surgeon  time  but,  except 
in  short  cases,  it  often  cripples  the  hand  by 
stiffening  the  fingers. 

Occasionally,  contractures  of  the  fingers 
follow^ing  the  treatment  of  a  cellulitis  of  the 
hand  and  forearm  may  be  due,  not  to  the 
cellulitis  itself  nor  to  the  incisions  made  to 
relieve  it,  but  to  fibrosis  and  shortening  of 
the  flexors  in  the  forearm,  the  result  of  too 
tight  bandaging  or  strapping.  Such  a  con- 
dition— Volkmann's  ischemic  muscle  contrac- 
ture— must,  therefore,  be  distinguished  from 
the  stiff,  flexed  fingers  produced  by  the  cellu- 
litis. Passive  motions  and  massage  are  help- 
ful in  both  conditions,  but  in  the  former  bone 
shortening  (radius  and  ulna)  is  necessary  to 
accommodate  the  contractured  muscles. 

Remember  that  chronic  ulcers  on  the 
hands  are  found  in  brass  workers,  and  that 
a  discontinuance  of  this  occupation  is  neces- 
sary to  secure  healing. 

Indolent  sinuses,  as  of  the  fingers  after 
deep  infections,  frequently  heal  by  the  daily 
use  of  prolonged  immersions  in  hot  water. 


103 


EATRErimE5. 


In  dealing  with  infections  or  injuries  of 
the  fingers  amputation  should  be  a  last  re- 
sort. This  is  especially  the  case  with  a  thumb, 
the  most  important  of  all  the  fingers. 

In  a  case  of  fresh  traumatic  amputation 
of  a  part  of  the  finger,  if  the  amputated  part 
has  not  been  too  lacerated  or  crushed,  try 
to  restore  the  member  by  cleansing  the  parts 
carefully  and  suturing  it  to  the  stump.  Once 
in  a  while  the  graft  will  "take." 

Amputation  of  a  finger  gangrenous  as  the 
result  of  carbolic  acid  application  should  not 
be  performed  until  the  line  of  demarkation  is 
well  established.  The  necrosis  may  be  su- 
perficial and  in  such  an  instance  the  finger 
may  be  saved  by  means  of  skin  graft. 

Lj^^^^  Persistent  pains  in  the  leg  may  be  due  to 

Extremity.  "obliterating  endarteritis."  This  occurs  oc- 
casionally even  in  young  men  and  often  goes 
on  to  the  production  of  gangrene.  The 
pathology  is  a  slowly  progressive  thrombo- 
angeitis. 

Flat-foot  is  another  cause  of  pains  in  the 
leg  or  thigh. 


104 


EATREniTIC5 


In  cases  of  pain  in  the  hip  of  doubtful 
origin,  examination  of  the  kidney  regions  may 
discover  the  cause. 

The  presence  of  sciatica  demands  a  care- 
ful exploration  of  the  pelvis  by  rectal  or 
vaginal  examination.  It  should  also  be  re- 
membered that  Osier  described  sciatica  as 
one  of  the  early  symptons  of  cancer  of  the 
breast. 

A  large  slowly  healing  superficial  ulcer  of 
the  leg  may  be  due  to  a  thrombosis  of  one  of 
the  small  vessels  leading  to  that  part.  Of 
course,  syphilitic  etiology  must  be  first  ruled 
out. 

Instead  of  suturing  the  skin  after  amputa- 
tion of  an  extremity,  it  is  sometimes  better  to 
bring  the  flaps  together  with  broad  strips  of 
adhesive  plaster,  aspecially  if  the  operation 
performed  is  for  an  arteriosclerotic  condition. 

During  the  course  of  a  pneumonia,  severe 
pain  in  the  leg  is  indicative  of  the  deposit  of 
a  septic  embolus  in  the  lumen  of  one  of  the 
veins,  which  often  results  in  an  ascending 
thrombosis  and  phlebitis,  necessitating  ampu- 
tation. 


105 


EATRErilTIE5. 


Severe  pain  in  the  knee  joint  with  redness 
and  high  pressure  may  mean  an  inflamma- 
tory condition  of  the  joint  or  adjacent  bone, 
but  it  also  may  be  due  to  a  phlebitis  of  the 
superficial  veins  of  the  leg. 

The  following  are  some  of  the  conditions 
in  the  presence  of  which  an  examination  for 
tabes  dorsalis  should  never  be  omitted :  1 . 
All  primary  swellings  of  the  knee  or  ankle 
joint  without  apparent  origin.  2.  "Sciatica" 
and  "lumbago."  3  A  deep  ulcer  on  the 
base  of  the  great  toe.  4.  Repeated  vomiting 
at  various  intervals,  with  periods  of  well- 
being  intervening.  5.  Abdominal  pains 
without  other  evident  cause. 

Pain  in  the  leg  after  an  abdominal  opera- 
tion often  means  the  development  of  a  fe- 
moral vein  thrombosis.  This  occurs  usually 
on  the  left  side. 

Lymph-edema  of  the  lower  extremity  as- 
sociated with  a  swelling  in  the  groin  (fluct- 
uating or  not)  is  significant  of  carcinoma  of 
the  inguinal  glands.  The  primary  lesion  may 
be  in  the  rectum,  e.  g.,  an  epithelioma  of  the 
anus  that  is  giving  no  symptoms. 


io6 


EATREMITIE5. 


When  removing  a  lipoma  or  other  growth 
from  the  inner  surface  of  the  thigh,  a  httle 
care  should  be  exercised  in  order  to  avoid 
cutting  the  long  saphenous  vein.  Ligature  of 
that  vessel  (especially  in  ambulant  and  in 
non-aseptic  cases)  may  be  followed  by  a  dis- 
tressing phlebitis. 

Inflamed  areas  and  abscesses  about  the 
knees  of  creeping  infants  should  be  exam- 
ined for  foreign  bodies. 

Punctured  wounds  about  the  knee  should 
be  treated  with  the  greatest  solicitude  and 
attention  to  asepsis,  in  order  to  prevent  in- 
fection of  the  joint. 

In  operating  for  loose  bodies  within  the 
knee  joint,  do  not  be  satisfied  with  removing 
but  one  body;  a  careful  examination  should 
be  made  to  determine  the  presence  of  more, 
for  they  are  very  frequently  multiple. 

Do  not  operate  for  foreign  body  in  the 
knee  joint  without  first  excluding  dislocation 
of  one  of  the  semilunar  cartilages. 

In  amputations  below  the  knee,  insist  on 
active  and  passive  motion  of  the  knee  joint 

107 


EATREniTIE5. 


at  an  early  date.  If  this  is  not  done  con- 
tracture ensues,  which  makes  the  application 
of  an  artificial  limb  difficult. 

Bilateral  swelling  of  the  knee  joints  without 
pain,  in  a  child,  is  due  either  to  syphilis  or 
tuberculosis,  more  likely  the  latter. 

Nurses  should  be  instructed  not  to  massage 
the  limbs  of  patients  who  complain  of  pain 
after  operation  or  confinement,  without  the 
order  of  the  attending  surgeon.  If  phlebitis 
and  thrombosis  are  present,  the  manipulation 
may  loosen  a  clot  and  cause  instant  death. 

Acupuncture,  followed  by  the  application 
of  the  Bier  cup  is  an  excellent  way  of  re- 
lieving dropsy  of  the  legs. 

A  hematoma  may  be  produced  in  the  calf 
muscles  by  direct  or  indirect  violence  that  the 
patient  may  pay  little  attention  to  at  the  time 
or  even  fail  to  recall. 

Swelling  of  the  leg,  associated  with  febrile 
disturbances,  may  be  produced  by  hematog- 
enous infection  of  a  hematoma  of  the  calf 
muscles.      Such  a   condition  may  somewhat 


io8 


EATREniTIES. 


simulate  osteomyelitis  or  other  serious  con- 
dition. It  may  be  differentiated,  however, 
by  the  location  of  the  greatest  tenderness  and 
swelling  and  by  a  careful  inquiry  into  the 
history.  If  no  distinct  traumatism  is  recalled 
the  condition  of  the  patient's  arteries  may 
nevertheless  suggest  the  possibility  of  the  oc- 
currence of  such  a  hematoma. 

Patients  with  varicose  veins  should  be  in- 
structed that  in  case  hemorrhage  takes  place, 
the  best  method  of  stopping  it  temporarily  is 
to  merely  compress  the  bleeding  point  with 
the  finger. 

Never  advise  an  elastic  stocking  in  cases 
of  varicose  veins  where  recent  phlebitis  exists. 
The  pressure  may  detach  a  part  or  whole  of 
the  thrombus,  propelling  it  into  the  general 
circulation. 

Chronic  leg  ulcers  very  often  heal  quickly 
under  the  Unna  zinc  oxide-gelatin  dressing, 
when  all  other  efforts  have  failed. 

Tenderness  in  the  heel,  or  pain  and  ten-        Toot. 
derness  in  the  sole  of  the  foot  is  very  often, 
indeed,  of  gonorrheal  origin.     It  will  not  be 


109 


EATREniTIES. 


relieved  in  such  cases  until  treated  on  that 
basis.  The  patient  may  deny  that  he  ever 
had  gonorrhea.  Examine  his  urine;  shreds 
tell  their  own  story. 

Do  not  be  too  hasty  in  ascribing  the  cause 
of  pain  in  the  tendo  Achilles,  or  Achilles 
bursa,  to  an  ill-fitting  shoe.  First  exclude 
gonorrheal  infection. 

If  the  cause  of  pain  in  the  feet  is  not  other- 
wise clear,  examine  them  in  the  dependent 
position.  This  may  develop  the  presence  of 
erythromelalgia. 

The  determination  of  the  presence  of  a 
fracture  of  one  of  the  mid-tarsal  bones  is 
extremely  difficult,  and  usually  impossible, 
without  x-ray  examinations.  Yet  these  ex- 
aminations have  shown  the  occurrence  of 
such  fractures,  alone,  or  associated  with  in- 
juries to  other  bones,  as  the  result  of  injuries 
by  slight  or  severe  direct  violence.  For  this 
reason,  and  because  fractures  of  the  meta- 
tarsals by  indirect  violence  are  by  no  means 
uncommon,  it  should  be  practically  a  routine 
to  submit  the  foot  to  skilful  skiagraphy  in 
all  cases  where  either  form  of  violence  may 


no 


EATREi^lTICS. 


have  occurred.  It  will  save  many  patients 
from  weeks  of  suffering  and  disability.  In 
this  region,  more  than  any  other,  the  x-rays 
are  a  means  of  diagnosis  that  cannot  be  dis- 
pensed with. 

Many,at  least,  of  the  sprains  of  the  ankle 
involve  a  fracture  of  the  tip  of  the  malleolus, 
and  should  be  treated  by  immobilization  in 
plaster-of-Paris. 

If  a  patient  complains  of  sharp  pain  in  the 
big  toe,  examine  the  urine  for  albumin  or 
sugar  in  order  to  exclude  a  diabetic  or  neph- 
ritic condition. 

In  old  people,  as  in  diabetics,  corns,  bun- 
ions and  wounds  of  the  feet  demand  the 
most  careful  attention.  They  are  often  the 
starting  points  of  gangrene. 

A  very  simple  method  of  curing  a  corn  is 
to  excise  it. 

In  ingrowing  toenail,  evulsion  of  the  nail 
gives  temporary  relief,  but  it  does  not  cure. 
When  the  nail  grows  out  again  the  condition 
recurs,  often  in  aggravated  form. 


Ill 


EATRErilTIE5. 


It  is  doubtful  whether  the  classical  opera- 
tions for  ingrowing  toe-nail  cure  permanently 
in  even  a  fair  percentage  of  cases.  Conser- 
vative treatment  will  usually  accomplish  as 
much,  even  in  the  presence  of  granulating 
masses.  This  treatment  includes  drawing  the 
flesh  away  from  the  nail  with  a  strip  of  ad- 
hesive plaster,  insertion  of  a  gauze  packing 
under  the  nail  edge  and  the  application  of  an 
absorbent  antiseptic  dressing. 

Be  very  guarded  in  the  prognosis  of  ul- 
cerations on  the  sole  of  the  foot  in  diabetic 
or  tabetic  patients,  no  matter  how  small  or 
trifling  the  ulceration  may  be.  They  persist 
for  long  periods  and  may  even  never  heal. 

PR  AC-  Very   often   the  unskilful   treatment   of  a 

fracture  is  worse  than  no  treatment  at  all. 
Serious  deformities  may  result  from  the  neg- 
lect of  small  details  no  less  than  from  the 
violation  of  important  principles. 

The  important  considerations  in  the  treat- 
ment of  fractures  are,  at  first,  relief  of  pain 
and  reduction  of  swelling,  and,  subsequently, 
preservation  of  function  of  the  muscles,  the 
nerves  and  the  neighboring  joints.       Hence 


TURE5. 


112 


rRACTURE5. 


the  value  of  early  and  frequent  massage  and 
passive  motion  (and  in  suitable  cases,  of 
active  motion)  and  the  necessity  of  avoiding 
splints  that  unduly  compress  the  muscles  or 
deprive  them  of  activity. 

In  the  treatment  of  fractures  of  the  fore- 
arm no  consideration  is  more  important  than 
the  avoidance  of  contractures  of  the  fingers, 
by  the  intelligent  use  of  splints  and  by  means 
of  early,  active  and  passive  movements. 

Permanent  contracture  of  the  muscles,  not- 
ably of  the  flexor  group  in  the  forearm,  may 
develop  within  a  very  short  time  after  the 
application  of  a  splint  that  exercises  undue 
compression.  It  is  a  wise  rule  to  inspect  all 
fracture  dressings  within  twenty- four  hours; 
and  when  this  is  not  expedient  special  care 
should  be  exercised,  when  applying  the  dress- 
ing, to  avoid  compression. 

In  very  many  cases  it  is  not  necessary  to 
the  diagnosis  of  fracture  to  elicit  crepitus 
and  abnormal  mobility — often  painful  man- 
ipulations. In  several  forms  of  fracture  there 
are  other  positive  diagnostic  evidences.  Thus, 
with  Colles'  fracture  the  level  of  the  styloid 
of  the  radius  will  almost  always  be  found  to 


113 


FRACTURES. 


have  receded  from  beyond  that  of  the  styloid 
of  the  ulna.  Moreover,  x-ray  examinations 
save  much  painful  manipulation. 

After  all,  the  localization  of  bone  tender- 
ness is  not  only  the  most  useful  sign  in  de- 
termining the  site  of  a  fracture,  but,  even  in 
the  absence  of  other  signs,  it  is  often,  in 
itself,  diagnostic  of  the  presence  of  a  frac- 
ture. As  instances  may  be  cited  greenstick 
fracture  of  the  clavicle,  and  fracture  of  the 
metacarpal  and  metatarsal  bones. 

In  all  examinations  of  children,  and  in  the 
examination  of  adults  for  suspected  fractures, 
leave  the  painful  manipulations  for  the  last. 

The  x-rays  have  taught  us  that  mathemati- 
cal reduction  is  rarely,  and  even  linear  re- 
duction is  seldom,  accomplished  even  in 
cases  in  which  excellent  functional  results 
are  secured.  Radiographs  have  thus  fre- 
quently been  made  the  basis  of  blackmail- 
ing damage  suits.  Nevertheless,  the  x-rays 
are,  of  course,  of  immense  value  in  the  treat- 
ment of  fractures — ^not  only  for  reference 
before  and  after  reduction,  but  during  the 
reduction  itself. 


114 


rRACTUKE5. 


A  fracture  produced  by  only  slight  vio- 
lence should  at  once  raise  the  suspicion  of 
a  malignant  growth.  In  such  cases  a  uni- 
form dark  shadow  about  the  bone  as  seen 
in  the  fluoroscope  is  to  be  interpreted  as  a 
neoplasm  rather  than  a  callus,  for  recent 
callus  is  not  opaque  to  the  x-rays. 

That  a  bone  appears  normal  by  fluoro- 
scopic examination  does  not  gainsay  the  pres- 
ence of  a  fracture.  A  fracture  of  the  radius, 
for  example,  may  occur  without  displacement 
of  the  fragments.  An  x-ray  plate  will  dem- 
onstrate the  line  of  fracture  when  the  fluoro- 
scope fails  to. 

Severe  localized  pain  after  traumatism,  es- 
pecially in  children,  may  be  due  to  sub- 
periosteal fracture,  e.  g.,  near  the  head  of 
the  humerus  or  the  femur.  Extreme  local- 
ized tenderness  is  the  chief  sign;  abnormal 
mobility  and  deformity  are  absent,  and  crepi- 
tus may  not  be  elicited. 

In  cases  of  fracture  where  the  end  of  the 
bone  lies  close  beneath  the  skin  do  not  place 
a  pad  or  any  pressure  whatever  over  this 
point. 


115 


rRACTURC5. 


In  compound  fractures  involving  loss  of 
continuity  do  not  needlessly  remove  any  piece 
of  bone  that  has  even  the  smallest  attachment. 
It  is  surprising  how  often  such  pieces  heal 
into  the  wound  and  thereby  help  to  save  loss 
of  substance. 

When  applying  a  plaster  dressing  to  the 
leg  always  include  the  foot  if  the  patient  is 
to  be  confined  to  bed;  otherwise  "drop  foot" 
will  develop. 

In  cases  of  fracture  of  a  rib,  it  is  neces- 
sary to  watch  the  patient  carefully  for  a 
couple  of  days  to  note  the  onset  of  a  possible 
lung  complication.  Localized  pneumonitis 
sometimes  occurs. 

In  severe  falls  or  blows  or  fractures  of 
the  pelvis,  catheterize  the  patient  as  soon 
after  the  injury  as  possible  in  order  to  dis- 
cover a  possible  rupture  of  the  bladder. 

Fracture  of  the  outer  end  of  the  clavicle 
may  follow  a  fall  upon  the  shoulder.  Un- 
less one  makes  a  careful  examination  such  a 
fracture  may  escape  observation  or  be  mis- 
taken for  a  dislocation  of  the  outer  end  of 


ii6 


PRACTURE5, 


the   clavicle,   with   which   condition,    indeed, 
it  may  be  associated. 

Shortening  of  the  shoulder,  as  measured 
from  the  sternal  end  of  the  clavicle  to  the 
acromion  process,  is  significant  of  fracture  of 
the  clavicle. 

In  the  aged,  pain  and  disability  in  the  arm 
after  traumatism  demand  especial  care  in 
examination  of  the  shoulder.  Fracture  of 
the  head  of  the  humerus  is  often  overlooked. 

In  fractures  of  the  anatomical  neck  of  the 
humerus,  examine  carefully  for  injuries  to 
the  brachial  plexus. 

The  radiograph  of  the  elbow  of  a  child 
shows  shadows  of  numerous  epiphyses.  One 
inexperienced  with  x-ray  plates  is  very  apt  to 
mistake  one  or  more  of  these  for  fractures. 
When  examining  the  skiagraph  of  a  child's 
elbow  suspected  of  fracture  or  dislocation, 
it  is,  therefore,  important  to  have  the  normal 
picture  in  mind,  or  better  yet  in  hand,  for 
comparison. 

Fractures  of  the  head  of  the  radius  are 
probably  more  common  than  generally  sup- 


117 


PKACTURE5. 


posed,  being  overlooked  frequently  because 
of  the  absence  of  the  ordinary  signs  of  frac- 
ture. 

A  patient  should  not  be  considered  neuras- 
thenic because  he  cannot  walk  after  union  of 
a  fracture  of  the  os  calcis.  There  is  often 
considerable  pain  due  to  adhesions  and  the 
incorporation  of  portions  of  the  tendo  Achilles 
in  the  callus. 

Pain  is  often  present  for  months  after  a 
fracture  of  the  leg,  especially  in  elderly  peo- 
ple. This  is  mainly  due  to  the  formation  of 
the  callus  and  needs  no  operative  interference. 
Of  course,  a  subacute  osteomyelitis  must  be 
kept  in  mind. 

If  a  small  child  has  been  pulled  by  the 
arm  and  thereafter  has  disability  in  that 
member,  attention  should  first  be  directed  to 
the  upper  end  of  the  radius.  Here  one  is 
apt  to  find  a  subluxation  of  the  head  of  the 
bone  ("pulled  arm")  or  an  epiphyseal  sepa- 
ration. 

Marked  tenderness  over  the  lower  end  of 
the  radius,  after  traumatism,  without  deform- 
ity, is  suspicious  of  fissure  of  the  bone.  Mo- 
bility or  crepitus  may  be  obtainable. 


ii8 


rRACTUKE5. 


The  silver-fork  deformity  is  by  no  means 
necessary  to  the  diagnosis  of  Colles'  frac- 
ture. 

If  a  patient  gives  a  history  of  "sprained 
wrist"  that  has  remained  feeble  and  pain- 
ful in  spite  of  appropriate  treatment  for  suffi- 
cient time,  and  if  the  wrist  presents  thick- 
ening and  tenderness  at  its  radial  aspect,  a 
diagnosis  of  fracture  of  the  scaphoid  should 
be  entertained.  Colles'  fracture  must  be  ex- 
cluded, by  the  relation  of  the  two  styloid  pro- 
cesses and  the  location  of  the  deformity. 
Fractures  of  the  radius  and  scaphoid  may, 
however,  coexist. 

Fractures  of  the  neck  of  the  femur  in  old 
people  sometimes  cause  no  other  symptoms 
than  disability.  The  mildness  of  the  trauma 
and  the  freedom  from  much  pain  should  not 
deceive  one. 

A  padded  triangular  wooden  or  card- 
board splint — one  leg  of  the  triangle  band- 
aged to  the  thigh,  and  another  to  the  trunk 
— makes  an  excellent  ambulatory  apparatus 
in  the  treatment  of  fractures  of  the  shaft  of 
the  femur  in  small  children.  It  maintains 
reduction,  leaves  the  leg  free  and  does  not 
interfere  with  keeping  the  child  clean. 


119 


PRACTURE5. 


LyriPHAT- 
IC5. 


Cardboard  splints  can  be  best  molded  to 
an  extremity  by  tearing,  instead  of  cutting 
them. 

When  operating  upon  a  fractured  patella 
it  is  very  important  to  sew  the  torn  lateral 
Hgaments  of  the  joint.  These  aid  largely  in 
the  support  of  the  joint. 

It  must  be  remembered  that  fractures  of 
the  metatarsal  bones  may  be  produced  by 
slight  injuries.  Thus,  the  base  of  the  fifth 
metatarsal  may  be  fractured  by  a  twist  of 
the  foot  while  walking  or  dancing. 

An  accurate  knowledge  of  the  lymphatic 
drainage  of  the  various  regions  of  the  body  is 
absolutely  necessary  before  one  can  deter- 
mine the  origin  of  a  glandular  infection. 
This  is  especially  important  in  cancer,  when 
sometimes  the  glandular  involvement  offers 
the  first  clue  to  the  primary  focus. 

Do  not  advise  extirpation  of  large  glands 
in  any  particular  region  without  making  sure 
that  they  are  not  the  early  manifestations  of 
leukemia  or  Hodgkin's  disease. 

If  a  bubo  shows  no  signs  of  disappearing 
under  wet  dressings,  ice  bags,  etc.,  and  evi- 


I20 


LyriPHATIC5. 


dences  of  suppuration  are  developing,  it  is 
better  to  make  a  clean  dissection  and  excise 
the  gland  without  opening  it  than  to  incise 
and  drain. 

Exposure  to  the  x-rays  causes  atrophy  of  5KIN. 

the  sweat  glands;  radiotherapy  is  proving 
the  most  satisfactory  treatment  for  hyperi- 
drosis. 

Pure  nitric  acid,  applied  on  the  narrow, 
blunt  tip  of  a  glass  rod  is  successful  in  the 
complete  destruction  of  verruccae,  but  only 
if  it  is  forced  down  to  their  very  roots. 

A  diffuse  blotchy  condition  of  the  skin 
should  not  be  diagnosed  as  measles  until  a 
careful  physical  examination  has  been  made. 
The  condition  may  be  the  expression  of  a 
streptococcemia,  as  from  an  osteomyelitic 
focus. 

Persistent  furunculosis  and  allied  suppur- 
ating skin  lesions  appear  to  yield  in  a  large 
percentage  of  cases  to  Wright's  vaccine  treat- 
ment. Stock  vaccines  are  usually  suitable  to 
such  cases.  The  internal  administration  of 
yeast,  calcium  sulphid,  etc.,  affords  only  oc- 
casional help. 


121 


5KIN. 


It  is  worth  while  bearing  in  mind  that  sub- 
cutaneous swellings  are  sometimes  gummata. 

Localized,  indurated  or  softening  skin  in- 
fections ("boils")  often  disappear  com- 
pletely or  open  painlessly  under  an  applica- 
tion of  emplastrum  plumbi  in  which  is  in- 
corporated 10  per  cent,  of  salicylic  acid;  or 
of  10  per  cent,  to  20  per  cent,  salicylated 
soap  plaster.  After  the  boil  opens  the  tiny 
dressing  should  be  changed  every  two  or 
three  hours. 

When  shaving  the  hair  in  the  neighbor- 
hood of  a  boil,  draw  the  razor  from  the  base 
to  the  apex  so  as  not  to  drive  microorganisms 
deeper  into  the  tissues. 

Do  not  treat  localized  subcutaneous  red 
and  tender  swellings  as  infections  without 
first  making  sure  that  they  are  not  evidences 
of  gout. 

Stains  of  anilin  dyes  may  be  removed 
from  the  fingers  with  strong  hydrochloric 
acid,  stains  of  iodin  with  aqua  ammonia, 
and  stains  by  silver  nitrate  with  potassium 
iodid  solution. 


122 


WOUND5. 


If  an  incised  wound  in  the  soft  part  does 
not  heal  as  readily  as  it  should,  examine  the 
urine  for  sugar. 

In  wounds  made  by  coal  on  the  exposed 
parts  of  the  body,  remove  all  the  particles 
of  coal  dust;  otherwise  a  disfiguring  pig- 
mentation might  follow. 

A  broad  clean  ulcer  on  the  soft  parts  may 
heal  per  primam  if  its  surface  is  swabbed 
with  iodin  and  its  edges  then  brought  to- 
gether with  adhesive  straps. 

An  ulcer  with  indolent  flabby  granulations 
may  be  stimulated  to  renewed  activity  by  a 
thorough  scraping  or  by  vigorously  rubbing 
it  with  gauze. 

Catgut  strands  do  not  always  make  a 
good  drain  for  wounds;  they  tend  to  swell 
and  occlude. 

Fresh  wounds  about  a  joint  should  not  be 
probed  to  see  whether  the  joint  has  been 
penetrated  or  not.  This  is  an  excellent  way 
of  infecting  it. 


123 


WOUND5. 


The  appearance  of  emphysema  in  the  tis- 
sues about  an  infected  wound,  accompanied 
by  fever  and  escape  of  bubbles  of  gas  from 
the  wound,  should  be  regarded  as  very  omi- 
nous, and  indicative  of  gas  bacillus  infec- 
tion. Such  cases  should  be  treated  by  ex- 
tensive incisions. 

Blank  cartridge  wounds  must  be  laid  wide 
open,  all  dirt  and  wad  carefully  removed, 
and  the  area  swabbed  out  with  tincture  of 
iodin,  or  with  pure  carbolic  acid  followed  by 
alcohol.  Tetanus  antitoxin  should  be  ad- 
ministered. 

If  the  powder  grains  are  not  properly  re- 
moved in  gunshot  wounds  of  the  exposed 
part,  unsightly  discolorations  result. 

The  posible  development  of  a  duodenal 
ulcer  in  cases  of  extensive  burns,  must  always 
be  borne  in  mind. 

Too  prolonged  or  too  rapid  and  vigorous 
use  of  the  pump  in  the  Bier  apparatus  will 
frequently  cause  a  rupture  of  the  superficial 
bloodvessels,  and  in  many  cases  severe 
sloughing  of  the  superficial  parts  ensues,  the 


124 


VOUIND5, 


result  of  the  treatment  being  worse  than  the 
primary  cause  of  the  trouble.  AppHcation 
of  the  Bier  cup  to  an  abscess  for  four  to 
five  minutes  twice  a  day  is  more  beneficial 
than  a  single  ten-minute  application. 

Soft  tumors  under  the  skin,  disappearing 
in  the  recumbent  posture,  are  usually  lym- 
phangiomata. 


TUriOR5. 


If  a  swelling  is  "fluctuating"  do  not  be 
too  sure  that  it  is  not  a  solid  growth.  Lym- 
phangiomata  fluctuate. 

A  subcutaneous  tumor  with  a  history  of 
a  puncture  or  the  presence  of  a  minute  scar 
in  the  overlying  skin,  usually  means  that  one 
is  dealing  with  an  inclusion  or  so-called  Ran- 
vier  cyst. 

In  hard  swellings  of  doubtful  nature 
marked  tenderness  is  significant  of  actinomy- 
cosis, when  acute  inflammation  may  be  ex- 
cluded. 

Do  not  give  a  good  prognosis  in  cases  of 
melanosarcoma  of  the  fingers  and  toes,  no 
matter  how  small  the  tumor  may  be,  and  no 


125 


TUnOR5. 


matter  how  high  the  amputation  is  performed. 
In  the  majority  of  cases,  these  patients  suc- 
cumb to  metastases. 

In  the  presence  of  a  pulsating  tumor,  es- 
pecially of  the  bone,  examine  the  kidneys. 
Secondary  hypernephromata  pulsate. 

A  pulsating  tumor  of  the  os  ilium  (en- 
dothelioma, sarcoma)  may  easily  be  mistaken 
for  a  gluteal  aneurism. 

The  "egg  shell  crackle"  of  certain  bone 
tumors  is  characteristic  of  multiple  myeloma. 
Examine  the  urine  for  albumose. 

In  cases  of  bone  tumor  these  organs  should 
never  be  overlooked  in  seeking  a  primary 
growth — the  prostate  or  mammary  glands, 
according  to  the  sex,  and  the  thyroid. 

An  amputation  for  malignant  ulceration 
should  not  be  performed  until  the  possibility 
of  its  being  merely  a  broken-down  gumma 
has  been  satisfactorily  excluded. 

A  metastatic  growth  in  a  superficial  lym- 
phatic gland  or  a  gland  of  the  skin  may 
sometimes    deceptively   simulate    the   appear- 


126 


TUnOR5. 


ance  of  a  sebaceous  cyst.  In  a  patient  suf- 
fering with  a  malignant  neoplasm,  therefore, 
the  development  of  a  "wen,"  especially  if 
at  an  unusual  situation,  should  be  regarded 
with  sufficient  suspicion  to  prompt  investiga- 
tion of  its  interior. 

Individuals  with  bluish  sclerotics,  and 
with  dark  lanugo  over  the  upper  part  of  the 
back,  are  usually  of  tuberculous  diathesis; 
and  these  signs  are  not  inconsequential  in 
making  a  diagnosis. 

Surgical  tuberculosis,  no  less  than  pul- 
monary tuberculosis,  calls  for  the  most  care- 
ful general  treatment,  post-operative  and 
otherwise.  Out-of-door  life  is  as  important 
here  as  for  phthisis. 

The  temptation  should  not  be  yielded  to 
to  incise  a  psoas,  hip  or  other  "cold"  ab- 
scess, except  in  isolated  instances  and  then 
only  under  the  most  rigid  asepsis.  The  pro- 
duction of  a  mixed  infection  means  chronic 
sinus,  chronic  invalidism  and,  often,  amy- 
loid disease. 


TUBER= 
CUL05I5. 


In  operations  upon  the  head  and  neck  the 
anesthetist  must  see  to  it  that  no  instrument 


ANES- 
THESIA. 


127 


ANE5THE5IA. 


is  allowed  to  lie  over  the  cornea,  especially  if 
it  is  exposed.  Ulceration  may  be  caused 
with  ease ;  it  is  often  healed  with  difficulty. 

During  narcosis,  when  stertorous  breath- 
ing calls  for  extension  of  the  jaw,  it  is  well 
to  hold  it  forward  on  one  side,  then  on 
the  other,  alternating  at  short  intervals.  Long 
continued  pressure  at  the  angle  or  angles  of 
the  jaw  produces  much  soreness.  Often  the 
jaw  can  be  kept  forward  by  catching  the 
lower  incisor  teeth  in  front  of  the  upper  ones 
(if  they  are  strong)  ;  a  single  finger  on  the 
chin  is  enough  to  maintain  this  position. 

In  light  narcosis  the  pupils  may  dilate 
reflexly  from  operative  manipulations.  This, 
of  course,  is  not  to  be  confused  with  the 
sudden  extreme  dilatation  that  occurs  when 
the  narcosis  has  been  carried  too  far. 

During  the  conduct  of  a  narcosis,  more 
important  than  the  activity  of  the  conjuncti- 
val reflex  or  the  actual  size  of  the  pupil  in 
determining  the  depth  of  the  anesthesia,  are 
the  changes  in  the  reactibility  of  the  lid  and 
the  alterations  in  the  size  of  the  pupil.  They 
are  reliable  indices  to  fluctuations  in  the  depth 
of  the  narcosis.     Sometimes  a  patient  is  quite 


128 


A1NE5THE5IA. 


relaxed  and  anesthetic  although  a  fair  con- 
junctival reflex  is  present;  and,  again,  it  may 
occasionally  happen  that  a  patient  reacts 
even  when  that  reflex  is  abolished. 

Avoid  touching  the  cornea  during  the  ad- 
ministration of  an  anesthetic.  The  ocular 
reflex  can  be  obtained  just  as  well  through 
the  lids,  and  the  pupils  and  motions  of  the 
globe  offer  the  most  definite  indications  of 
the  degree  of  narcosis. 

In  crying  infants  it  is  extremely  difl^icult  to 
determine  the  presence,  and  location,  of  ten- 
der areas.  This  may  be  readily  accom- 
plished by  the  administration  of  chloroform 
to  the  extent  of  primary  narcosis.  The  phy- 
sical examination  then  becomes  very  easy 
and  when  a  tender  spot  is  handled  it  will  be 
announced  at  once  by  lively  reflexes. 

During  the  performance  of  a  hernia  op- 
eration it  is  often  helpful  for  the  anesthetist 
to  allow  the  patient  to  react  sufficiently  to 
strain  into  view  a  sac  that  has  slipped  back 
into  the  abdomen. 

A  convenient  way  in  which  the  anesthetist 
may  carry,  all  sterilized  and  ready   for  in- 


129 


ANE5THE5IA. 


stant  use,  his  hypodermatic  solutions,  is  the 
following:  Shallow,  wide-mouthed,  half- 
ounce  bottles  are  sterilized,  labeled  and  filled. 
Over  the  mouth  of  each  bottle  is  then 
stretched,  and  hermetically  fastened,  a  cover 
of  sterilized  rubber  (dam).  Before  the 
narcosis  is  begun  the  anesthetist  disinfects  his 
syringe  and  sets  these  bottles  in  a  dish  of 
sublimate  solution.  This  sterilizes  the  sur- 
face of  the  rubber.  When  a  solution  is 
wanted  the  needle  of  the  hypodermatic 
syringe  is  simply  thrust  through  the  rubber 
and  as  much  as  is  needed  is  drawn  into  the 
barrel.  The  puncture  hole  closes  without 
leakage.  The  covers  of  the  bottles  need  to 
be  changed  only  occasionally. 

Whenever  the  arrangement  of  a  patient 
upon  the  operating  table  requires  an  extrem- 
ity to  occupy  a  constrained  position,  that  po- 
sition should  be  shifted  from  time  to  time 
to  avoid  pressure  paralysis.  The  anesthetist 
should  never  draw  the  arms  alongside  the 
head,  nor  permit  the  strap  of  a  leg-holder 
to  press,  for  more  than  a  few  minutes  at  a 
time,  upon  the  brachial  plexus  in  the  neck. 

Nitrous  oxid  narcosis  can,  in  most  cases, 
be  continued  "smoothly,"  with  no  cyanosis 


130 


ANE5TME5IA. 


and  with  fair  degree  of  relaxation,  even  for 
an  hour.  A  laparotomy  may  thus  be  per- 
formed, if  ether  and  chloform  are  contrain- 
dicted.  To  secure  such  a  narcosis  it  is  best 
to  use  an  apparatus  that  permits  exhalation 
into  the  gas  bag,  and  which  has  a  valve  for 
the  admission  of  air.  The  bag  should  not  be 
distended  fully.  After  brief  air  and  gas 
administrations,  air  is  turned  off  and  the  pa- 
tient breathes  N^O  and  his  own  CO2.  At 
short  intervals,  and  whenever  there  is  any 
cyanosis,  a  single  breath  of  pure  air  is  al- 
lowed. 

Ten  grains  of  trional  (or  veronal)  the  night 
preceding  the  operation,  and  a  quarter  of  a 
grain  of  morphin  one  hour  before  operation, 
will  make  an  anesthesia  easier  and  more  com- 
plete and  it  will  not  be  followed  by  the  usual 
after-effects  of  a  complete  narcosis. 

Local  anesthetics  cannot  be  injected  pain- 
lessly into  tense,  inflamed  areas  unless  the  in- 
jection is  begun  at  a  point  in  the  skin  well 
beyond  the  seat  of  inflammation. 

The  admixture  of  adrenalin  to  cocain  so- 
lution counteracts  much  of  the  depressant 
efFect    of    the    anesthetic    and    enhances    the 


131 


A1NE5TME51A. 


local  vaso-constriction.  When  the  mixture 
is  used  on  the  surface  of  a  mucous  mem- 
brane, however,  as  in  excising  an  ulcer  in 
the  mouth,  one  must  be  prepared  for  a 
marked  reactionary  bleeding. 

INFUSIONS.  ^^^  ^  single  intravenous  infusion,  as  to 
combat  the  shock  of  hemorrhage,  it  is  not 
essential  that  the  solution  contain  any  of  the 
blood  salts  but  the  most  abundant  one — 
sodium  chlorid.  For  repeated  infusions,  how- 
ever, as  sometimes  used  in  treating  various 
toxemias,  it  is  better  to  employ  also  the  other 
salts,  the  solution  being  made  of  sodium 
chlorid  0.9,  potassium  chlorid  0.03,  calcium 
chlorid  0.02,  water  100. 

Intravenous  saline  infusions  in  too  large 
volume  are  harmful  by  the  production  of  con- 
gestion of  the  internal  viscera.  One  to  one 
and  a  half  pints  is  enough  for  an  adult  of 
average  weight 

In  performing  subcutaneous  infusion  do 
not  allow  too  much  fluid  to  accumulate  at 
one  area,  otherwise  necrosis  may  occur.  Shift 
the  needle  to  various  parts  not  by  swinging 
it  from  side  to  side,  but  by  partly  withdraw- 
ing it  and  reinserting  it  to  another  area. 

132 


POST-OPERATIVE 


The  pain  in  the  lower  part  of  the  back 
that  is  so  frequently  complained  of  after  op- 
eration, can  be  best  relieved  by  placing  a 
small  pillow  in  the  hollow  of  the  spine. 

In  determining  the  cause  of  a  post-opera- 
tive fever  never  fail  to  look  at  the  throat. 

If,  after  a  period  of  post-operative  cathe- 
terization, the  patient  finds  herself  able  to 
pass  urine  spontaneously,  apply  hot  towels 
to  the  vulva. 

Gastric  lavage  is  the  best  post-operative 
anti-emetic. 

Vomiting  may  frequently  be  controlled  by 
one-drop  doses  of  tincture  of  iodin  in  water 
at  half-hourly  intervals. 

The  distressing  thirst  after  abdominal  op- 
erations, where  fluid  by  mouth  produces  vom- 
iting, is  best  relieved  by  subcutaneous  infu- 
sions of  normal  salt  solutions  or  by  the  in- 
sertion of  a  tube  into  the  rectum  connected 
with  a  bag  of  saline  solution  placed  just  above 
the  level  of  the  patient's  hips,  allowing  the 
injection  of  water  drop  by  drop  and  so  slowly 


133 


P05T-0PEKATIVE. 


that  no  irritation  of  the  rectum  is  set  up.  The 
patient  may  in  this  manner  receive  small  quan- 
tities of  water  for  hours. 

Excessive  purgation  and  too  frequent 
enemata  before  operation  may  be  productive 
of  a  great  deal  of  post-operative  distention. 

The  tension  on  the  sutures  after  an  opera- 
tion for  epigastric  hernia  may  be  relieved  by 
placing  a  pillow  under  the  knees  and  propping 
the  patient  up  in  bed. 

A  post-operative  distention  that  is  not  re- 
lieved by  a  high  enema  can  often  be  reduced 
by  washing  out  the  stomach. 

After  operating  on  diseased  bone,  the 
wound  should  not  be  dressed  too  often.  The 
fine  granulations  which  form  are  very  liable 
to  be  pulled  off  with  the  removal  of  the 
packing. 

Before  putting  an  unconscious  patient  to 
bed,  the  hot  water  bags  should  be  removed 
or  sufFiciently  covered  to  prevent  the  occur- 
rence of  a  burn. 


134 


P05T-0PERATIVE. 


The  occurrence  of  post-operative  phlebitis 
is  often  encouraged  by  keeping  the  patient  too 
long  in  bed. 

Old  people  should  be  allowed  to  sit  up  or 
get  out  of  bed  as  soon  after  operation  as 
possible  in  order  to  avoid  post-operative  lung 
complications. 

Do  not  allow  patients  to  lie  on  the  back 
immediately  after  an  operation  involving  the 
vertebrae  or  the  sacrum;  a  disagreeable  ne- 
crosis of  the  skin  flaps  may  rapidly  take 
place. 

In    differentiating    shock    and    concealed       liCriOR= 
hemorrhage  progressiveness  of  the  symptoms       RJiAOC  AND 
is  very  significant  of  continued  bleeding.  SHOCK 

Restlessness,  increasing  pallor,  increasing 
air-hunger,  increasing  weakness  of  the  pulse, 
falling  temperature  (subnormal),  and  the 
ephemeral  effect  of  stimulation,  all  point  to 
hemorrhage  rather  than  shock.  In  addition, 
there  is  often  some  local  sign  or  symptom. 

In  post-operative  collapse  if,  after  study- 
ing the  symptoms,  there  be  any  doubt  whether 


135 


MEnORRHAOE  AND  5MOCK. 


the  condition  be  due  to  shock  or  to  concealed 
hemorrhage,  the  wound  should  be  opened  and 
bleeding  sought  for. 

In  dealing  with  secondary  hemorrhage 
from  the  rectum  (whether  bleeding  vessels  are 
tied  or  not) ,  it  is  better  to  tampon  with  gauze 
wrapped  about  a  piece  of  stout  rubber  tub- 
ing, than  with  gauze  alone. 

The  application  of  elastic  bandages  to  the 
limbs  to  cut  off  their  blood  supply,  will  in- 
crease the  amount  of  blood  going  to  the  vital 
centers  and,  therefore,  is  very  beneficial  to 
patients  who  have  been  operated  upon  in  a 
condition  of  shock. 

Raising  the  foot  of  the  bed  twelve  inches 
may  combat  shock  more  quickly  than  the  re- 
peated administration  of  stimulants  and,  by 
the  way,  is  far  less  harmful  to  the  patient. 
One  should  remember  not  to  use  this  means 
in  abdominal  cases  where  pus  has  been  found 
in  the  peritoneal  cavity. 

In  many  cases  of  shock,  a  venous  infusion 
will  more  often  save  life  than  dallying  with 
stimulants  which  merely,  in  the  end,  serve 
to  tire  out  the  heart. 


136 


5EP5I5. 


Bone  tenderness,  especially  of  the  sternum 
and  tibiae,  is  frequently  significant  of  sepsis. 

In  seeking  the  source  of  an  obscure  sepsis, 
do  not  overlook  an  examination  of  the  is- 
chiorectal region. 

Small  petechiae  on  the  skin  may  indicate 
a  sepsis  of  obscure  origin. 


Aluminum  instruments  should  not  be 
boiled  in  soda  solution  like  other  instru- 
ments. They  are  to  be  sterilized  by  boiling 
in  plain  water  or  by  passing  them  through  an 
alcohol  or  Bunsen  flame. 


irS5TRU» 
riENT5. 


Woven  catheters  may  be  sterilized  by 
boiling  in  saturated  ammonium  sulphate  solu- 
tion. Catheters  and  bougies  may  be  kept 
aseptic  if  they  are  wrapped  in  gauze  wet 
with  the  soap-spirits  of  the  German  pharma- 
copeia. 

Warming  a  laryngeal  mirror  prevents  con- 
densation of  the  breath  upon  it  for  only  a 
short  time.  The  mirror  will  remain  bright, 
however,  throughout  a  prolonged  examina- 
tion if,  instead  of  warming  it,  its  surface  is 
smeared  with  an  invisible  film  of  soap. 


137 


IN5TRUrimNT5. 


Dipping  a  throat  mirror  in  alcohol  will  as 
effectively  keep  off  a  film  of  moisture  as  heat- 
ing it. 

An  "invalid  table,"  the  shelf  of  which 
projects  over  the  patient's  body,  will  be 
found  a  great  convenience  during  operations 
as  a  receptacle  for  instruments  in  immediate 
use.  It  saves  time  and  temper,  and  avoids 
accumulation  of  instruments  on  the  patient's 
body. 

When  scissors  become  "catchy"  their 
edges  can  often  be  surprisingly  smoothed  by 
carrying  each  blade  repeatedly  from  lock  to 
tip  between  the  firmly  pressing  thumb  and 
forefinger.  Each  kind  and  size  of  scissors 
has  its  own  capacity,  and  should  be  used 
only  for  what  it  is  intended.  Ophthalmic  in- 
struments are  not  intended  for  ordinary  dis- 
sections, tissue  scissors  should  not  be  used  for 
cutting  bandages,  nor  bandage  scissors  for 
plaster-of-Paris. 

Bandage  knives  cut  best  when  they  have 
a  "saw  edge,"  which  is  easily  secured  by 
sharpening  them  on  a  window  sill  or  other 
rough  stone. 


138 


IN5TKUriEINT5. 


A  scroll-saw,  with  an  assortment  of  a 
dozen  saws,  can  be  purchased  at  the  hard- 
ware store  for  twenty-five  cents;  it  is  ideal 
for  resection  of  the  small  bones  of  the  hand 
and  foot,  for  amputation  of  the  digits,  etc. 

Well  tempered  carpenter's  chisels  and 
gouges,  and  a  carpenter's  wooden  mallet 
answer  the  purpose  admirably  for  bone  work. 
A  useful  bone  drill  can  also  be  selected  from 
the  stock  of  the  hardware  dealer. 

A  gardener's  pruning  knife  and  a  car- 
penter's miter  saw  are  the  best  tools  for  the 
removal  of  plaster  dressings. 

A  cheap  potato  knife,  rough  sharpened 
on  a  stone,  is  excellent  for  cutting  through 
starch  bandages. 

Crochet  needles  are  most  useful  for  lifting 
buried  stitches  out  of  a  sinus. 

Knitting  needles  find  another  purpose  as 
a  means  of  rupturing  the  membranes  when 
this  is  needed  in  obstetrical  work. 


139 


IN5TRUriENT5. 


Sharp  and  blunt  retractors  may  be  fash- 
ioned, in  an  emergency,  by  bending  the  tines 
of  a  fork  and  the  handle  of  a  spoon,  respec- 
tively. 

A  teaspoon  is  also  useful  as  an  elevator  of 
the  eye,  when  resection  of  the  superior  max- 
illa is  performed. 

An  inverted  tea-strainer  is  useful  in  the 
dressing  after  colostomy,  to  prevent  pressure 
of  the  gauze  upon  the  gut. 

A  spoon-shaped  potato  cutter  may  be 
used,  in  an  emergency,  as  a  wound  curette. 

The  multiple  surgical  uses  of  the  hairpin 
are  also  well-known.  Of  stouter  material,  if 
necessary,  a  small  self-retaining  retractor  can 
be  quickly  made  from  steel  wire;  it  often  ob- 
viates the  need  of  an  assistant  when  search- 
ing the  hand  or  foot  for  a  foreign  body. 


Similarly,  applicators,  probes  and  de- 
pressors may  be  improvised  by  twisting  stout 
copper  wire. 


140 


HN5TRUriElNT5. 


A  wedge  of  hard  wood  makes  a  gag 
quite  useful,  often,  when  administering  anes- 
thesia. 

A  discarded  thermometer  case  (or  a  hard 
rubber  douche  point)  is  a  serviceable  handle 
in  which  to  mount,  with  paraffin  or  adhesive 
plaster,  a  stick  of  silver  nitrate. 

A  bright  and  altogether  satisfactory  light 
for  throat  examinations  can  be  had  cheaply 
by  covering  a  1  6-candle-power  Edison  elec- 
tric bulb  with  a  smooth  layer  of  plaster-of- 
Paris,  about  three-eighths  of  an  inch  thick, 
leaving  on  one  side  an  aperture  the  size  of 
a  silver  half-dollar,  or  larger.  The  white 
inner  surface  of  the  plaster  brilliantly  re- 
flects the  light.  The  outer  surface  may  be 
painted  black. 

Cheap  powder  blowers,  such  as  are  used 
for  insecticides,  may  be  employed  as  insuf- 
flators in  surgical  work,  and  pepper  boxes  are 
useful  for  dusting  powders. 

Steel  spring  tape-measures  are  better  than 
the  wires  generally  sold  for  the  purpose,  for 
conducting  to  an  x-ray  tube  the  current  from 
the  coil  or  static  machine;  easily  kept  taut. 


141 


IN5TRUriENT5. 


and  quickly  adjusted,  they  are  safest  for  the 
patient  and  most  convenient  for  the  operator; 
that  they  are  not  insulated  is  inconsequential 
— the  coverings  on  the  regular  wires  do  not 
insulate  the  induced  current. 

Wooden  skewers  are  serviceable  nail- 
cleaners.  Rolling  pins  and  kitchen  towel 
racks  are  very  convenient  for  adhesive  plaster, 
rubber  tissue,  etc.,  especially  for  hospital 
dressings. 

A  probe  that  has  become  bent  and  twisted 
is  readily  straightened  out  by  rolling  under 
the  foot  on  an  even  floor. 

The  weight  scale  is  the  most  important  of 
all  instruments  in  determining  the  presence  of 
a  latent  carcinoma. 

Hot  bricks  or  stones  retain  their  heat  much 
longer  than  hot  water  bags. 

A  barrel  cut  in  two  on  its  long  axis,  makes 
an  excellent  holder  for  bed-clothes  in  acute 
affections  of  the  lower  extremities.  Not  only 
does  it  avoid  the  heavy  pressure  of  the  cover- 
ings but  it  diminishes  the  chances  of  discom- 
fort caused  by  jarring  of  the  bed. 


142 


5UTURE5. 


The  threading  of  catgut  or  kangaroo  ten- 
don through  a  needle-eye  not  very  roomy  may 
be  made  easy  by  cutting  the  suture  end 
obliquely  and  flattening  it  between  the  han- 
dles of  the  scissors.  Silk  must  not  be  cut 
obliquely,  however,  for  this  makes  it  apt  to 
ravel  while  it  is  being  threaded. 

Silkworm-gut  is  easily  dyed,  and  inciden- 
tally impregnated  with  an  antiseptic,  by  im- 
mersing it  for  twenty- four  hours  in  one  per 
cent,  solution  of  methyl  violet,  before  the 
boiling. 

When  suturing  a  wound  of  the  scrotum, 
if  the  tissue  (dartos)  is  contracted,  apply  a 
warm  compress  for  a  moment  to  cause  re- 
laxation. 

In  removing  a  skin  suture,  pull  up  on  one 
side  and  cut  it  as  close  to  the  skin  as  possible. 
This  is  in  order  to  avoid  drawing  any  of 
the  exposed  part  of  the  suture  through  the 
wound  and  thus  possibly  infecting  it. 

Woven  silver  wire  for  suture  material  in 
a  recurrent  hernia  will  often  succeed  when 
all  other  means  fail. 


143 


5UTUKE5. 


One  is  wise  in  making  assurance  doubly 
sure  by  tying  each  fascial  suture  with  three 
knots  instead  of  two. 


EAAMIN" 
ATIOIN5. 


Everything  is  to  be  gained  and  nothing  to 
be  lost  by  having  patients  remove  enough  of 
their  clothing  to  allow  of  a  completely  satis- 
factory examination  in  all  cases.  Instances 
can  be  called  to  mind,  by  any  physician,  of 
erroneous  judgments  arrived  at  before  ex- 
posure of  other  parts  of  the  body  showed  con- 
ditions altering  one's  opinion.  Especially 
is  it  important  to  compare  the  corresponding 
members  of  the  body  on  the  sound  and  the 
affected  side,  in  all  doubtful  cases. 


When  a  skiagraph  shows  a  condition  not 
recognizable  at  once  as  a  definite  lesion,  it  is 
important  to  make  an  x-ray  picture  of  the 
corresponding  part  of  the  body  on  the  other 
side.  It  may  show  that  the  condition  is 
merely  a  symmetrical  peculiarity,  and  not  a 
pathological  one. 

Free  ammonia  in  the  urine  of  a  diabetic  is 
a  prognostic  sign  and  its  presence  is  a  con- 
traindication to  operation  in  diabetic  gan- 
grene, for  it  shows  the  presence  of  beta-oxy- 
butyric  acid  in  the  blood. 


144 


EAArilNATION5. 


Before  excluding  glycosuria  examine  both 
morning  and  evening  specimens  of  the  urine. 

If  a  patient  persists  in  running  evening 
temperatures  which  cannot  be  accounted  for 
after  a  thorough  physical  examination  and 
blood  examination,  one  should  place  the  pa- 
tient on  increasing  doses  of  the  iodids,  for 
the  fever  may  be  due  to  an  old  syphilitic 
infection. 

When  performing  an  office  operation,  too 
great  care  cannot  be  taken  to  sufficiently  roll 
back  or  remove  such  articles  of  clothing  as 
might  become  soiled.  The  patient  may  not 
say  much  if  he  is  obliged  to  draw  up  a  gar- 
ment wet  with  blood — but  he'll  probably 
think  a  few  things. 

Tar-paper  is  a  smooth,  fairly  waterproof 
material  to  tack  on  the  floor  when  preparing 
a  room  for  operation. 

Grocers'  paper  bags  are  well-adapted  re-     DRE55IIN05. 
ceptacles  for  soiled  dressings. 

In  the  Bier  treatment,  the  cup  will  stay  in 
place  without  other  assistance  if  zinc  oxid 

145 


DRE55IN05. 


salve  or  vaselin  is  applied  to  the  skin.  Even 
better  than  this  is  a  piece  of  smooth  rubber 
tissue  which  protects  the  skin  from  irritation 
by  the  pus. 

By  addling  a  one- fourth  per  cent,  or 
stronger,  solution  of  boracic  acid  to  Burow's 
solution  (aluminum  acetate),  the  latter  clears 
at  once,  if  cloudy,  and  remains  permanently 
free  from  turbidity  or  precipitation. 

Yellow  salve  soon  turns  brown  on  expo- 
sure to  light,  if  made  with  lard  as  a  base. 
Cold  cream  or  lanolin  makes  a  good  base. 
Keep  in  a  procelain  jar  with  a  screw  top. 

When  a  "wet  dressing"  fails  to  properly 
drain  a  septic  wound  try  a  glycerin  dressing 
— gauze  wrung  out  in  pure  glycerin  and  cov- 
ered with  waterproof  material. 

When  wet  dressings  are  needed  on  hairy 
areas  it  should  not  be  forgotten  that  they 
predispose  the  hair  follicles  to  infection. 

Wet  dressings,  especially  the  very  useful 
Burow's  solution  of  aluminum  acetate,  when 
applied  to  the  hand  or  foot,  usually  cause 


146 


DRE55IN05. 


maceration  and  whitening  of  the  skin,  which 
is  apt  to  alarm  the  patient.  The  addition  to 
the  solution  of  one-fourth  its  bulk  of  glycerin 
or  alcohol,  will  obviate  this  unsightly  macera- 
tion. 

A  bichlorid  of  mercury  dressing  should 
never  be  applied  on  an  area  of  skin  on  which 
tincture  of  iodin  has  been  recently  painted. 
An  iodid  of  mercury  is  formed,  which  is 
highly  irritating. 

Ichthyol,  if  used  in  ointment  sufficiently 
strong  (25%  to  50%),  is  perhaps  the  most 
useful  single  medicament  in  aborting  early 
superficial  infections. 

The  addition  of  a  little  oil  of  citronella 
to  an  ichthyol  ointment  robs  it  of  its  dis- 
agreeable odor. 

2%  ointment  of  fuchsin  in  vaselin  or 
zinc  oxid  frequently  yields  gratifying  results 
in  stimulating  the  epidermization  of  indolent 
ulcers  and  granulating  wounds. 

Subiodid  of  bismuth  dusted  on  an  oozing 
granulating  wound  promptly  stops  the  bleed- 
ing. It  is  also  an  excellent  stimulant  to  the 
growth  of  epithelium. 


147 


DRE55I1N05. 


An  ointment  of  beta-naphthol,  10;  sul- 
phur, 45 ;  lard,  24 ;  and  green  soap,  enough 
to  make  1 00  parts,  is  useful  in  removing 
gun-powder  not  too  deeply  situated  in  the 
skin.  It  must  be  employed  cautiously,  how- 
ever, to  avoid  a  destructive  dermatitis. 

Gauze  is  preferable  to  cotton  for  padding 
the  axilla  or  breasts  in  dressings  that  are  not 
frequently  renewed.  Cotton  easily  becomes 
matted  with  sour-smelling  secretions  and  thus 
sets  up  dermatitis.  The  skin  over  the  tendo 
Achilles  and  about  the  heel  cannot  be  too 
carefully  padded  when  applying  Buck's  ex- 
tension apparatus. 

Collodion,  commonly  used  to  seal  a  punc- 
ture wound,  as  after  aspiration,  will  not  ad- 
here if  the  spot  is  wet  or  bleeding.  To  ob- 
viate this,  pinch  up  the  skin,  wipe  it  dry,  ap- 
ply the  collodin  and  continue  the  compres- 
sion a  minute  or  so  until  the  collodion  has 
begun  to  contract. 

When  rubber  tissue  is  not  at  hand  to  make 
a  "cigarette  drain,"  rubber  tubing  may  be 
used  in  its  place.  Split  a  piece  of  tubing  of 
appropriate  length,  and  lay  the  wick  of  gauze 


148 


DRE55HN05. 


in  the  trough  thus  made,  or  draw  the  gauze 
through  the  tube  with  a  probe.  Fenestras 
may  be  cut  as  desired. 

Swabbing  out  with  glycerin  a  sinus  filled 
with  exuberant  granulations  will  dehydrate 
them,  making  them  fresh  and  healthy. 

A  urethral  endoscope  will  be  found  a 
great  help  as  a  means  of  introducing  a  rub- 
ber drainage  tube  into  a  narrow,  tortuous 
sinus. 

The  painfulness  of  withdrawing  packings 
that  have  dried  in  a  wound  may  be  avoided 
by  soaking  them  with  peroxid  of  hydrogen. 

The  pain  of  a  severe  burn  may  be  much 
relieved  by  covering  the  part  with  flat  pieces 
of  gauze  soaked  in  liquor  Burowii  and  pro- 
tected by  rubber  tissue,  or  by  the  application 
of  a  10%  ichthyol  ointment  on  flat  pieces 
of  gauze. 

The  change  of  dressings  of  burns  may  be 
made  painless,  and  the  growth  of  epithelium 
encouraged,  by  employing  next  to  the  wound 


149 


DRE55IN05. 


sterile  strips  of  gutta-percha  in  the  same  man- 
ner as  for  skin-grafts.  Subiodid  of  bismuth 
lightly  dusted  on  the  granulating  surface 
stimulates  epithelial  growth. 

Patients  will  appreciate  the  use  of  black 
bandages  for  the  scalp — where  they  are  com- 
paratively inconspicuous,  and  for  the  hands 
— where  they  do  not  soil. 


Mastoid  and  scalp  dressing  may  be  re- 
duced in  bulk,  and  the  uncomfortable  neck 
turns  of  the  bandage  avoided,  by  the  use  of 
starch  bandages,  which  hold  neatly  and 
firmly. 


Bandages  may  be  fastened  in  place  more 
neatly  and  more  securely  with  strips  of  ad- 
hesive plaster,  than  with  safety  pins.  When 
bandaging  a  finger  or  toe,  turns  about  the 
hand  or  foot  will  be  unnecessary  if  the  dress- 
ing is  fastened  down  with  a  narrow  strip  of 
plaster  run  over  the  top  from  base  to  base, 
and  another  strip  circularly  about  the  dress- 
ing at  the  base  of  the  digit.  When  using 
black  bandages,  employ  black  adhesive 
plaster. 


ISO 


INDEX. 


Abdomen 

Anesthesia 

Appendix 

Back     - 
Bile  Tract 
Bladder 
Brain 
Breast 

Cranium 

Dressings 


43 

127 

61 

93 
49 
76 
12 
35 

10 

145 


Ear            --._--.  12 

Examinations      -----  144 

Extremities     -                 -        -                 -  94 

Bye      -------  18 

Face          -------  26 

Foot     -------  109 

Fractures          ---_..  112 


Generative  Organs,  Female 
Genito-Urinary  Tract 
Glands,  Lymphatic 


85 

72 

120 


ii                    INDEX. — Continued. 

PAGE 

Hand        ------ 

99 

Head             ------ 

7 

Hemorrhage    ----- 

135 

Hernia          ------ 

64 

Infusions          -        _        .        .        - 

132 

Instruments          ----- 

137 

Intestines         ----- 

57 

Kidney          ------ 

72 

Lower  Extremities 

104 

Lymphatics          ----- 

120 

Mouth      ------ 

27 

Neck             ------ 

30 

Nose         ------ 

24 

Penis             ..---- 

80 

Pharynx            ----- 

27 

Post-Operative     .         -        -        -        - 

133 

Prostate           ----- 

79 

Rectum         ------ 

67 

Scalp        ------ 

7 

Scrotum       ------ 

83 

Sepsis       ------ 

137 

Shock            ------ 

135 

Skin          ------ 

121 

Stomach       ------ 

53 

Sutures            ----- 

143 

INDEX. — Continued.  Hi 

PAGE 

Testicle 83 

Thorax          --..-.  ^g 

Tracheotomy  ------  34 

Tuberculosis         -         -         .         .         .  127 

Tumors 125 

Upper  Extremities      -         -         .         _  ^ 

Urethra              80 

Ureter           -         -         .         .                  .  ^2 

Urinary  Tract          -----  ^2 

Wounds 123 


COLUMBIA  UNIVERSITY  LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE          1 

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RD33 
Briokner 


B76 
1909 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  33  B76  1909  C.1 


2002108690 


